Blood Pressure: How High is Too High and How Do I Lower it Safely?

Blood Pressure: How High is Too High and How Do I Lower it Safely?

 

Blood Pressure: How High is Too High and How Do I Lower it Safely?

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I’m gonna speak about one of my favorite subjects, which is high blood pressure. And it’s one of my favorite subjects for many reasons. I’m a primary care general internist and it’s by far and away, the most common thing that family physicians and general internists and other primary care clinicians do in primary care practices is, help patients with their blood pressure. In addition, when we look at worldwide health, depending on which study you read, there’s some evidence that high blood pressure is the number one cause of preventable deaths worldwide. Others would argue tobacco is on that list or maybe diet is on that list, but certainly high blood pressure is on the very, very top of that list. If not first, then in the top three. In addition in the United States, we know that the rates of heart disease and stroke have been declining, particularly heart disease. And when we determine why that is, we know that a lot of the progress has been from the way we treat heart attacks and strokes in the intensive care unit, but over half of it is from the way we work with prevention of heart attacks and strokes with the treatment of common risk factors as we call them. And the three most important, again, are tobacco high blood cholesterol and high blood pressure. And again, you could debate amongst those three, which has had the most impact, but again, treatment of high blood pressure, control of high blood pressure is on the short list. Now having said all that, another thing we know is that if you look at population studies, having a lower blood pressure is healthier than having a high blood pressure. And in fact, that relationship starts at pretty low blood pressure levels. In other words, if your blood pressure is even over 110, 120, your risk statistically of having a heart attack or stroke begins to increase. but it’s a very small amount for any given patient. And despite that observational evidence, that epidemiologic evidence, we still have a tremendous amount of controversy about at what level to actually begin treating it. And if we’re gonna treat it, how to treat it. And so that’s my plan for tonight, is to address some of those larger questions, both big and small related to the management high blood pressure. And I’ll do that by first telling you that I have no conflicts related to the material or any of the medications or devices I’m gonna speak about tonight. And this is my roadmap. This is what I hope to cover for you tonight. I’m gonna begin with something that’s very basic, which is how do I know if I have high blood pressure and the corollary to that is what is the best way to measure it? So we’ll spend more time than you expect on that subject, ’cause it turns out it’s really, really important. How can I lower my blood pressure without medications? When do I need medications? At what threshold do we begin treatment? Is it 160, 150, 140, 130, 120, what’s the right number? And then if you do need treatment for high blood pressure, what medications are best? We’ll touch on all of those issues and several others along the way. Now, the other reason why I chose this subject for this year is because (clearing throat) there’s a tremendous amount of controversy about this subject in the medical community. And I’ll spend some time discussing that with you, but as you know, clinicians now make a lot of decisions in office practice, (clearing throat) excuse me, based on clinical guidelines. And so many different groups of experts write guidelines based on their reading of the best evidence, published the guidelines. And we seek consensus. And in many things that we do over the years, we’ve developed certain consensus around, say screening for colon cancer, or mammography between the ages of 50 and 69, or not doing pap tests under age 21. These are things where we as a community of experts have come together and almost all the guidelines are consistent and aligned with each other. But as you’ll see in the treatment of high blood pressure, we have guidelines that are uniquely distinct from each other and have major impacts. So depending on how you read the evidence and or how, which guideline you choose to follow, it really leads to big differences in whether you need medications, and if so, how many? And so I’ll try to touch on all of those things. So let’s talk with measuring blood pressure, and this is a humbling topic to talk about because you can get your blood pressure measured now in the supermarket and the pharmacy and hair salons and buy equipment from Amazon or your local medical supply store, the MAs on medical assistance, so the nurses will check it when you come in to see the doctor or the dentist. And so there’s a lot of numb… And you can of course check it at home. And so there’s a tremendous amount of measurement of blood pressure being done. And the take home message here is that we are very poor at accurately measuring blood pressure. And I recently wrote a paper on this, and if you wanna read more of the references there asking the question, which is how can we treat blood pressure correctly if we’re not measuring it correctly? And I would argue, we don’t measure it correctly in any of the settings in which we have the opportunity to measure it. So let me review that a little bit. It’s also humbling to talk about this because for any of you who are health professionals, yourselves, or have family members or who are health professionals, this is the almost the first thing everyone learns. And yet despite that, we do it quite imperfectly as a profession. Now this is confusing because there are three different ways, they’ll actually be a fourth that I’ll mention as well, to measure blood pressure. And it has to do with the setting in which we measure it. So the most common is you go into someone’s office, a doctor, a nurse practitioner, whomever, and they measure your blood pressure. So that’s called office measurement and that’s actually been our gold standard. So when we look at studies of treatment of high blood pressure, almost all of them have used office measurement as the gold standard. But of course you can also measure blood pressure at home. And if you do that, (clearing throat) if you include home measurement as part of someone’s regimen, it turns out that the patients end up using less medication, but they also have less good blood pressure control. And so it’s a little bit of a trade off ’cause you tend to get lower numbers on average, when you measure at home, and I’ll say more about that. And then the third option is something we called an ambulatory monitor, and these have been around for decades, but they’re very underutilized. And what they are as you would wear a blood pressure cuff, you could wear it for 24 hours or 18 hours while you’re awake, it can be programmed to automatically take your blood pressure no matter what activity you’re doing. And it gives us an average blood pressure done robotically, if you will, over the course of 18 hours or 24 hours. And it turns out from some recent evidence, these ambulatory monitors, this 24 hour average, correlates to the best with strokes and heart attacks. And when I use that abbreviation CVD, I’m talking about cardiovascular disease, which includes heart attacks and strokes. Now we have these three different categories of blood pressure, and it turns out they measure different things and they don’t correlate all that well with each other. Sometimes in medicine, if we comparing diagnostic tests with each other, we compare them to a gold standard and we can describe the characteristics of the test, which patients they might miss, which patients they might over detect. The problem here is that we don’t know which is the gold standard. So we can compare them to each other, but we don’t really know what is the objective truth. So what we end up with is three different strategies for measuring blood pressure that we have to interpret each one on its own. Now the medical community has reached consensus on how to measure correctly. And the last time I counted from one of the official guidelines that I’ll make reference to later, there were 19 different elements that constituted an accurate blood pressure measurement. Now I’ve summarized these into eight, but it includes all 19. I’ve just combined a few. But what I want you to do as I go through these is think about the last time you had your blood pressure measured in the office and which of these were followed and which of these were not. And that’s really the punchline. And we’ll also get to the second punchline, which is when you’re measuring your own blood pressure at home, you should do the same things that I’m about to describe that the clinician should do in the office. And so again, think about how you’re measuring your blood pressure at home and which of these best practices you’re following. So one of the most important things is that you need to be seated for five minutes before the blood pressure is taken. So in my office, what happens often the patients have trouble. They’re late for the appointment. They’re having trouble finding parking, there’s traffic around the office. They finally get in the parking spots are painted too tight. Finally, get it in, you almost hit the posts. You rush upstairs, the elevator stopping at every floor. You finally come in, there’s still time to get checked in by the nurse. And she sits you down and she starts reviewing your chief complaint and starts reviewing your medications. And while she does that, she’s cranking up the blood pressure. (audience laughing) So there are about six things wrong with that particular scenario. And one of the most important is to allow the body to equilibrate before the blood pressure is measured. While the measurement is done, the back should be supported, and the feet on the ground. Now, even in my own office where I see patients personally, I cannot do this because I have an exam table. And the way the exam table is positioned to the cuff on the wall, I don’t… It’s not an exam table, it goes up and down. So my patients don’t have their back supported and don’t have their feet on the ground, even in my own office. So you’re not supposed to take any caffeine exercise or smoking for 30 minutes. I’ll say more about caffeine later. Caffeine is not associated with high blood pressure chronically, but in the short term, if you drink a cup of coffee right now, it can increase the blood pressure. My personal favorite is no talking. So no talking by the patient and no talking by the person who’s taking the blood pressure. So this is one, certainly that these initial blood pressures were often done incorrectly. There should be no clothing under the cuff. Another common mistake. So often your blood pressure is being taken in a public setting, the cuff is put on over your clothes. That’s incorrect. The arms should be supported at the level of your heart, the atrium, one of the chambers of the heart. So usually on a table or on the clinician’s arm, but up in this relaxed position. And probably the most important of all, or one of the most important of this list is a correct cuff size. And so most of the blood pressure cuffs you purchase, if you don’t go out of your way to ask for a larger cuff will be too small. And that’s true for because of obesity and overweight. That’s true cause of excess skin folds. That may be true cause of excess muscle mass. But in our society, in my practice, I hang up the large cuff, I take out the other ones I set them aside, and I never use them all day long. ‘Cause the large cup will fit almost everyone. And if the large cuff is too large, you do not get a falsely low value. The only thing that all of these different factors do is give you a value that’s too high. So basically what we’re doing is over diagnosing high blood pressure by the incorrect measurement of blood pressure. And that’s true in the office, and that’s true at home. So again, that’s a long list. It’s a lot of time spent on this simple subject, but I think it’s on the very short list. One of the most important things we can do to improve the way we manage high blood pressure. And as I implied, this is also true at home. So remember all of these things, when you’re checking blood pressure at home, these are the best practices that you should follow at home. – [Man] Can you comment regards how tight to make the way cuffs? – Let’s take your questions at the end for the editing purposes. But the question was how tight to make the cuff. The cuff is automatically, it’s marked where to the fit it around the arm. Uninflated it should be comfortable. And when you’re inflated, it gets tight. and the tightness is derived by how many millimeters of mercury you inflated to. So if your blood pressure, if I think your blood pressure might be 180, then I need to go higher than 180 in order to come down to get that measurement correct. And if I get up to 200, it’s gonna hurt. If I think your blood pressure is 130, I might go up to 160 and that would feel on the comfortable side of tight. So the cuff itself just comfortably around that. So it stays on the arm by itself basically. and then the pressure is what determines that feeling that, ooh, that hurts a little or that’s too tight. The other controversy is what blood pressure to count. And what do you write in the chart, or what do you write on your log at home? Most of the guidelines in the United States talk about doing repeated measurements and averaging them. That’s okay. It’s a little hard to do the arithmetic in your head. You know, you have to be, slick with the… Write down the value ’cause you’ll forget. Write down the second value than average the two that one can do that. In the office it gets a little more complicated because the medical assistant or nurses taking a blood pressure or two then do I count his or hers and then my own and average those two, or they do it twice myself and just average my two. So there’s a lot of uncertainty about the best practice. But it turns out, and I’ll show you this in a few slides. It turns out that the acceptable way, and this is true. The Canadians do it this way. And in fact, most of the quality measures in the United States do it this way, is you can record the lowest value. So if you’ve taken it two or three times, you don’t have to average, but you record the lowest one. And our definition of blood pressure control is determined using the lowest value. So many people make an error on that as well. Now all of these things can lead to a dramatic increase in blood pressure, and I’m talking dramatic. 30 points millimeters of mercury. On average people report about 20, but some people it can be substantially higher. So if your blood pressure is high, one of the first things to do is repeat it. And in fact, a study was just done that was published earlier this year. And it was a study from 20 different clinics in a city like ours. And the medical assistants were instructed on these 19 features that I just reviewed of taking the blood pressure best practice. And then they were instructed with one other thing, which was, they were told if the blood pressure is elevated over in this case, 140/90, take it again. And just by taking it a second time, the blood pressure was under 140/90, over a third of the time. So repeating the measurements routinely give you a lower measure measurement in part maybe because that resting is happening now a little bit, that’s settling down that we talked about and so on. So that’s a very easy trick, is just take it again, and you can record the lower of the values. And as I talked about, this is an ongoing controversy and different practices do this differently, but I think when you look at quality measures in the United States, including the ones we use from the federal government that are called HEDIS Measures or like the Kaiser’s do in their population studies and so forth, the quality community accepts the lowest measurement when two or three values have been taken. But the guidelines still often talk about averaging multiple measurements. Now there’s also something that’s not common. I call it research grade measurement. And the way this was done in this one particular study, which I’ll come back to called the SPRINT Study, the Systolic Blood Pressure Intervention Trial, they had the medical assistant take the blood pressure akin to the way we would in the office, and then they would instruct the patient to go into a quiet room that was with them dim lighting. They would have an automatic machine, a robotic machine, to take the blood pressurement. They would sit for five minutes. They had three automated measurements with some pause in between. There was no human in the room. All the different 19 features were being adhered to, and the blood pressures were averaged. And what was fascinating about this is that when they compared the values they got in the dark room with the automated measurement, it was 12 and a half points lower than what the nurse got in their advanced high blood pressure setting. This is a place where people were coming to see experts to participate in a big study. And even in that big study compared to the robotic dark room, the dark room was 12 and a half points lower. Keep that in the back of your mind, because you’ll see this study turns out to be one of the major studies that has influenced some of the guidelines that suggest we should treat people at much lower values. And so it’s a little bit of a catch 22. If you’re gonna use the research grade measurement, which is 12 points lower, then treating at a lower threshold may be okay. But if you’re gonna measure it the way we normally measure it, then may be treating it at the higher threshold is also okay. And you’ll see where the guidelines fall out in that regard. But remember this robotic measurement. And what we may see in the future is that more people will move to this. It would be pretty easy to do in a busy office setting. You just set up, you need an extra room and a robot, just an automated machine basically and it’s pretty easy to do, but it’s not how it’s currently done. (clearing throat) Now, the other issue that has become part of common practice led by consumers and also device makers is to measure the blood pressure outside the office. And there is a consensus about doing this. In fact, the U.S. Preventive Services Task Force as early as 2015, so several years ago, as part of their official recommendations for blood pressure management, suggested that measurements should be a pain outside the clinical setting, meaning outside of the physicians, nurse practitioners office, before starting treatment. This is not common practice. Most clinicians continue to treat based upon their own measurement, but it is interesting because many of us follow the U.S. Preventive Services Task Force guidelines for other things like cancer screening. But in this case, it hasn’t really been fully integrated into a common practice. People use home measurement for a variety of things, but it’s not that common to use it routinely as a second test, if you will, before you begin treatment. However, in England, that’s what they do. And so the blood pressure has to be checked outside of the office before the patient gets treated, especially with medications. All right, let me move next to home measurement briefly. I’ve already said several things about this, and it turns out this is not well standardized. You all, if you’re measuring your blood pressure at home, you’re all doing it in your private time and space, and I have no idea how you’re doing it. I barely know how my medical assistant is doing it, but I certainly don’t know how you’re doing it. Although one good trick is to bring your machine in with you when you see your clinician and demonstrate to them how you are taking it, which gives you the opportunity to also make sure the cuff size is correct, that your technique is correct, the machine is a well standardized machine, correlates with the office measurement and so on. So that’s not a bad little trick if you wanna be a little bit more precise in your home measurement. It’s also not fully evidence-based, and what I mean by that is when patients are assigned blood pressure treatment with home measurement and compared to blood pressure treatment without home measurement, and that’s the only extra intervention, there’s no benefit of home measurement. Now that’s a little misleading because if you did a real comprehensive program of blood pressure control, that included pharmacy involvement and home checks and frequent checks and combination pills and things like that, and home measurement, that is part of an integrated comprehensive plan, home measurement can be a useful tool. But when it’s been isolated, as the only extra thing that’s done, it doesn’t help that much. It’s a little bit like checking blood sugars in people who are on pills for diabetes, where, now I’m not talking if you’re taking insulin, then you must check your home blood sugar. But if you’re just taking pills, depending on the pills, many patients do not need to check their home blood sugar, and it’s not associated with a very significant change in diabetes control. And this is analogous to that. Correct home monitoring requires all 19 of those other elements. So everything that I suggested in the office you should do at home and therefore again, bringing your equipment in and having the nurse or physician watch you take your blood pressure is a good way to make sure that your own skills are up to best practices. And again, things like correct equipment is also extremely important. And that’s complicated now ’cause there’s so much new equipment. Many, many of the new devices have not been well-validated. And so people are selling all sorts of things on fingertips and wrists and so forth. And many of those measurements have not been validated in rigorous studies. And when they have been studied in rigorous studies do not correlate particularly well with the measures that I’m discussing. The correct timing is interesting because as I mentioned with the ambulatory monitor, it’s around the clock. And so you could argue that doing home measurement that mimics the ambulatory monitor might make sense, and that’s not a bad way to do it. So rather than checking it every day or every day twice a day, or whatever, you could argue, maybe I’ll check it five times a day, one day per month, akin to my using an ambulatory monitor, so getting a measurement throughout the day, because the blood pressure goes up and down in a diurnal rhythm over the course of a 24-hour period. It’s highest in the morning and it’s lowest in the evening. So if you’re checking your blood pressure after dinner, especially after a glass of wine, kids are asleep, everything’s copacetic, you’re gonna get a lower blood pressure then, than if you check it when you first wake up in the morning before you’ve taken your medications. So that’s important to know. And so what our current guidelines are, you can do this all day, one day, every now and again model, but the standard recommendations are to check it in the morning before you take your medications and then before dinner, as a way to frame the higher and lower. But I don’t recommend. They’re very, very few patients who need to do this every day. You get too much information, you get too worried about it. It’s not adding value, but it is something to do occasionally and keep track of it. And again, share that information with your clinician. Home measurements, as I mentioned, are lower than office measurements. And sometimes people talk about having different normals, but the relationship is not uniformly predictable. So I can say if your blood pressure is 145 in the office, it’s 135 at home. It could be, but it might not be. So it’s not a fixed relationship. On average, it’s lower, but in any individual patient or any individual measurement, the correlation is a little bit better than a coin flip, but not a ton better. It’s about 60 or 70% correlation. And as I mentioned, when you isolate home management as the only intervention, the evidence has shown little impact. All right, the final part of this section is to talk about ambulatory blood pressure monitoring. And again, this is a machine you would normally pick it up from the cardiology suite or where you might get an electrocardiogram or maybe an echocardiogram, or certainly a Holter monitor. That’s where these live. They’re relatively inexpensive. Medicare will cover these, especially if the right diagnosis is put down, the right diagnosis being elevated blood pressure, ’cause you’re using it to help decide whether someone has hypertension, which is the disease, versus not hypertension. So Medicare will pay if you use elevated blood pressure. And again, I already described how it works, you can program it to do anything you want, typically it’s several times an hour while you’re awake. And usually a few times at night, most people can sleep through this. Again, it’s slower than the office, but the relationship is unsettled. But as I mentioned, the recent studies, including a very thorough review by the U.S. Preventive Services Task Force has suggested that it predicts amongst a population of people, who’s gonna get into trouble with cardiovascular disease than the other tools. That is to say it’s makes blood pressure measurement the most predictive risk factor for heart disease and stroke compared to office measurement or home measurement. So it’s available, it’s safe. It’s not that expensive, but we use it quite infrequently in modern American medicine. And I think one of the things I favor is using it a bit more because misdiagnosing someone with high blood pressure usually means a lifetime of medications. ‘Cause it’s rare once people get diagnosed with high blood pressure that they get undiagnosed with high blood pressure, that requires a little bit of courage on the patient’s part and the clinician’s part. It also is the best way to detect something that’s been called white coat hypertension. And this is that syndrome where your blood pressure is high in the office and low everywhere else. That does exist. It’s more common in women than men. It’s more common in young than old. It’s more common in Caucasians than African-Americans. So it does exist. It’s most common in young Caucasian women. And when you see an elevated blood pressure in the office as a young woman, which is very important to diagnose correctly because of the impact it can have on pregnancy, but it can also be over-diagnosed. And that’s a setting where careful home measurements or an ambulatory monitor can be particularly important. You can also use it to monitor treatment and for some other purposes. So in summary, this simple task that we do from the pharmacy to the hair salon, to your home, to my office, to the cardiologist’s office, turns out to be a little bit more complicated than we thought. And from a clinician point of view, we talk about really rethinking the office workflow. I think who’s ever taking the blood pressure it’s good to repeat the measurement. Whoever you’re working with should think about whether to take averages or record the lowest value. Home measurements are good. We probably do it more than we need to, but less accurately than we need to. So if you’re gonna do it and do it well, but maybe a little less often, and make sure you’re following best practices, particularly things like cuff size breasts and so forth. And again, similarly, the ambulatory monitor should be used more. Probably doesn’t need to be used in every patient or even every patient with nuance and high blood pressure. But we certainly, whenever we have a sort of a tiebreaker, and a patient doesn’t wanna be on meds, for example, and the clinicians thinking, eh, I mean, you should be on meds, perfect situation to get another data point and get the average under the curve and the area under the curve and use the ambulatory monitor. All right, so I’m gonna move on. That’s what I have to say about measurement. I think that’s the longest section of the talk but I think probably the most impactful of the way it would, if done correctly, change how we as clinicians practice and how you manage your own blood pressure at home. (clearing throat) I wanna speak briefly about treating high blood pressure without medications. This is something I’ve been interested in since early in my career. As many of you know, I studied nutrition before I came to medical school and I’ve looked for the interface between nutrition and internal medicine and chronic illness for my entire career. And one of the first studies I ever participated in was a study that compared what we call nonpharmacologic or non-drug therapy for high blood pressure with drugs. That study, it was a great study. We had 300 patients that we recruited and we managed them very carefully. My job was to teach them how to manage it without drugs. And at the end of a year of followup, the drugs won hands down. And in fact, the NIH had funded that study and they had funded about a dozen others at the same time. And every single study showed the same thing, the drugs outperform non-drug treatment uniformly across the board. So medications are very effective for lowering blood pressure. We’ll see more about that in a minute. And nonpharmacological therapy is a relatively modest tool in your toolbox across all patients. But for individual patients, it can be the answer. And so in the study, we were looking at the average blood pressure between 300 patients or 150 on the non-drug and 150 on the drug, but for an individual patient, the things I’m about to talk about can be extremely effective and can either slow the need to take medications or allow you to take one less medication, or in some cases completely, treat the blood pressure without medication. So it’s a very potent tool in the toolbox for a motivated patient, especially one who has certain clinical characteristics. Now, one of the most important or predictive characteristics is if you’re overweight or obese. And so if your weight is high and you have high blood pressure, and there’s a close correlation of those two things, then weight loss is uniformly effective at lowering high blood pressure. So if a patient can lose 20 pounds and keep it off for a year or so, the blood pressure will go down a ton and it’s worth at least one or two different pills or classes of medications. The problem is that it’s really hard to lose 20 pounds and keep it off. But for the patient, who’s at that point where you’re ready to do that, then weight loss always works at lowering blood pressure. And it’s quite well sustained. Now, eventually as you gain weight, or even if you kept the weight off as you age, you’re at risk of the blood pressure drifting upward again over time, but you can delay medication for quite some time if you’re effective at treating high blood pressure with weight loss and those that are overweight. Alcohol can also raise blood pressure. You don’t have to become a teetotaler if this is the case, but if your blood pressure is high and you’re a moderate to heavy alcohol user, three, four, five drinks a day kinda class is the way some of these studies were done, and can get down to one drink a day, the blood pressure can come down quite nicely. Although the amount you’ll see is smaller than with weight loss, but it’s a real effect, but there aren’t that many patients who drink that much and are willing to stop drinking just for a little bit of blood pressure control. They’d rather take a medication I think in many cases. Salt intake is something I’ll say more about, but we’ve recommended salt restriction or sodium restriction for decades for high blood pressure. It’s part of our public health recommendations for a healthy diet, and the numbers are complicated and I won’t review them particularly, but in general, restricting sodium can lower blood pressure very effectively, but only in some patients. And it’s probably somewhere about a third to a half. And so it’s a very effective tool for treatment of high blood pressure in some patients, but it’s more controversial about whether the whole society needs to lower our salt intake. In other words, ’cause a lot of patients with high blood pressure won’t benefit from sodium restriction, but if you have high blood pressure and if you’re on a high sodium intake, and if you’re African American in particular or older in particular, both of which are associated with reduced clearance of sodium by the kidney. So reduce handling of a salt load, if you will, then sodium restriction can be quite important. Some of the recommendations in the past have recommended extreme sodium restriction that doesn’t work and may be dangerous. And again, moderate sodium intake for most people is fine, but it’s a tool in your toolbox if you wanna give it a try, especially if you’re not overweight, and if you don’t drink that much, then it’s third on the list and it’s worth a try, and I’ll come back to that in a minute. There’s something called the dash diet, which has been around for about 15, 20 years, which is basically just a heart healthy diet. So all the principles of eating a healthy diet with mostly plants, not too much real food and relying on mostly fruits and vegetables, whole grains, small amounts of meat, fish, and fowl, nuts and oils, and so on, a Mediterranean type diet or a heart healthy diet, that’s been shown to lower blood pressure. And in fact, it’s additive with sodium restriction. So if you combine a heart healthy diet and sodium restriction, the blood pressure goes down further. Physical activity can lower blood pressure. We recommend physical activity for everyone anyway, as I like to say, physical activity is Biblical and that means you should do it six days a week and one day of rest. The recommendations are 30 plus minutes a day. And that if you’re start sedentary and you get to that point can lower the blood pressure by five to 10 millimeters of mercury. And as I implied earlier, a habitual caffeine consumption or coffee consumption is not associated with the risk of high blood pressure. In fact, coffee consumption seems to be the Teflon substance that it’s not been shown to be bad for almost anything, but certainly the studies that have looked at mortality, heart disease risk, cancer risk, stroke risk and the like, have shown caffeine to be not associated with bad outcomes in general. Now clearly it can make you irritable. It can give you GI problems. It can cause atrial fibrillation in some people. But in general, when you look at populations, caffeine as a fatigue, mitigator, as we call it with the residents is safe and effective. Once upon a time when I was a nutrition graduate student, I used to say, and I had a slide that said this, it was a while ago, that a third of the salt in the human diet comes naturally occurring in food, a third comes from food processing and a third comes from us as consumers at the stove or at the table. And that now is just totally wrong. We’ve evolved over those 40 years to the point where our diets are different and our sodium sources have changed to the point now where processed and restaurant foods account for almost 80% of our salt intake. So still a small amount from naturally occurring in foods and still some at home. But if someone tells you or someone suggest to you or for your own reading suggests that you wanna be in a lower sodium intake, worrying too much about what you do with the stove or the table is most likely the wrong tactic. And what you need to do is not purchase anything in a bag or a box or a can, unless it says in really big letters, low salt, because anything in a bag or a box or a can is high salt, unless it says otherwise. And so the whole story of when you go to a big market, only shopping on the outer aisle of the market, where the produce is and the dairy and so forth makes very good sense. So don’t limit your consumption of things in general that are in a bag, or a box, or a can, if you’re concerned about your salt or for that matter current dietary recommendations. Secondly is restaurant food and other package and prepared foods. So a lot of the services that are out there delivering food, but particularly restaurant food. I don’t know if any of you have gotten into the game of weighing yourself every day and the night after you went to your favorite, whatever restaurant that’s particularly high in soy sauce or whatever, and your weight goes up four pounds and you say, “This is not possible. “I didn’t eat anything yesterday.” But then you realize you went and had sushi or your favorite Thai food restaurant. And it was all because of the sodium intake. So those changes in weight are all salt and water, so a couple of days later it’ll come off. But that’s showing you how much sodium is in that food that you ate at the restaurant. And the worst culprit of course is fast food. So not to pick on Asian cuisine, but fast food is by far and away the biggest culprit here. And of course in our society, that’s a concern. So sodium restriction is if you’re eating a mostly plant diet and you’re eating your nice tomatoes and you wanna put some salt on it and that makes you more tomatoes, that’s a good thing to do. Or if it helps you consume your lettuce and your big salad, do it because that’s healthy, but going to a fast food restaurant or buying food, that’s in a bigger box or can is not. All right. I’m gonna move next to some of the clinical questions that are most on the mind of clinicians working with patients with high blood pressure in terms of medication management, labeling and so forth. And most of what we know about high blood pressure over the course of the last decades, most of all of my career, have been from an entity called the Joint National Commission. And this is a NIH brought together panel of experts. They meet every five to seven years or so, and they come up with different recommendations, and over the years they’ve defined what’s a normal blood pressure. They’ve recommended certain types of drugs over other drugs and so on. And the most recent one was a few years ago. It was the eighth version of this, and they asked three questions and this was good because they were three really good questions, the three questions that we all care about, which is, does treatment of blood pressure at a certain level of elevation work? If so, how low should I treat it? Good questions. And third, what medication should I use? Does it matter? And what they did was, which was different than the seven previous Joint National Commissions, is they only looked at what we call Randomized Clinical Trials, which is the highest level of medical scientific evidence, where there’s a control group, a blinded evaluation of large populations of patients. And there had been several dozen of these that met the criteria for various questions related to high blood pressure. And they came out with nine recommendations. I’m not gonna read them all. I’ll summarize. The one that was most surprising, I wouldn’t call it controversial at first, but it was definitely a surprise, was the recommendation that for people over 60 years old, which is a lot of the population that has high blood pressure in the United States, that we could use 150 as our cut point rather than 140. So this was really great news for primary care and really great news for patients. Because if it meant we can let people ride a little higher, then that means one less medication, typically, less side effects, less cost and so on. So this was a very good recommendation, very popular recommendation amongst the primary care community, but others didn’t react so favorably as I’ll show you. And they recommended lowering it below 150 and also lowering a second number, the lower number, the diastolic blood pressure to less than 90. So this was a surprise, but favorable, and it wasn’t pulled out of the sky and I’m not gonna review this, But each of these abbreviations stands for a really big, well done, publicly funded randomized clinical trial of the treatment of high blood pressure. And so they looked at a very large body of evidence in order to make this conclusion. So it was very, what we would call, evidence-based. The other recommendations were not as controversial. They said for everyone else under 60, then you should use 140 as your cut point. Or if you’re treating both the high number or the low number using 90 as the low number. I should just point out it turns out that the high number is more important than the low number. When I was in medical school, that wasn’t the case. We mostly focus on the lower number, what we call diastolic hypertension. But it turns out that systolic hypertension is the most predictive of cardiovascular disease, heart disease and stroke. At the time these studies were being analyzed, the diabetes community was trying to suggest that lower values would be better, but they reviewed the evidence carefully and said, even in diabetics, it doesn’t really matter. People with kidney disease, CKD stands for Chronic Kidney Disease, didn’t matter, You could use 140. And people were pushing that in the African American community, where there was a lot of risk associated with hypertension that lower numbers might be better. They looked at that literature and said it doesn’t matter. And so basically they concluded that 140/90 was fine for everyone, that there were many patients over 160 that you could let ride a little bit and drift up to 150. Although they also said if the patient was under 140 and well-controlled, that was fine too. So you were given some flexibility for people over age 60. The medications they recommended were four, and previous recommendations have favored one class over another. They were a little bit more agnostic, gave us a smorgasbord of four medications, except it was really four ways to get to three, because two of them shouldn’t be used together. So the four categories are thiazides, which are water pills, weak water pills, but which have independent blood pressure lowering effect. CCB stands for Calcium Channel Blockers. I’ll give you the specific names of some of these in a minute. Those work. ACEI stands for ACE Inhibitor and other I’ll give you the names. And the fourth category are angiotensin receptor blockers, or ARBs, and they also can be used as the first class of drugs. The one corollary here was not to use ACE and ARB together. So you could use ACE or ARB, either first, second, or third, and then thiazide first, second, or third with calcium channel blockers for a second or third. So that was sort the modern menu. And that was again good for patients, ’cause there were a lot of medicines in these classes, good for physicians, ’cause they’re medicines we knew how to use. You’ll note or you may note that one class of medicine that’s not on this list are beta blockers. And beta blockers have been used for high blood pressure for many, many years, they’re very good for other conditions. But when studied compared to these four drugs, they’re not as effective as a single therapy. But that’s a little misleading because they’re excellent as the third or fourth drug or they’re excellent if you need it for something else. So it still lowers your blood pressure, just not quite as evidence-based in terms of preventing strokes in particular as these other four classes of medicines. But it’s still on the list, we use it all the time. It’s very effective way to lower blood pressure, but just not as the first or second drug as the main blood pressure lowering treatment. And something that not everyone knew, although it’s been in the literature for several decades is that ACE inhibitors and angiotensin receptor blockers do not work as well in African Americans as the other classes of drugs. So they specifically went out of their way and said for African Americans, we recommend thiazides or calcium channel blockers first. Again that’s also a little misleading because many patients need, most patients need more than one medication. And again, once you’ve gotten to drug number three, you begin to go to back to ACE and ARB very quickly in African Americans, but you would start with thiazide diuretics or a calcium channel blocker as your drugs of first choice. And in kidney disease, that’s the one disease with specific recommendations, especially if you’re spilling protein in the urine, then ACE inhibitors and ARBs have a long history of helping preserve kidney function. But that’s really more in the context of having chronic kidney disease than just bland essential hypertension. So those were the recommendations and we read this and said, all right, that’s sensible. They asked the right questions, they looked at the right body of evidence. These are patient-centered, good for primary care, everything was good. And then the sky fell. (audience laughing) But these are the medicines that, just to show you some of the names, these are not the brand names, these are the generic names or the chemical names, but you may still recognize them ’cause many of these medications have been around for decades. They’re all generic, they’re inexpensive. they’re on everyone’s formulary, not necessarily all of them in each category, but one from each category is on everyone’s formulary. And so it’s pretty easy to find an ACE inhibitor that works. An enalapril or lisinopril are pretty common. Angiotensin receptor blockers. Losartan is probably the most common. Valsartan is the one that had a little bit of imperfections in the synthesis. So that’s been out of circulation of late, but there are others in that class. The calcium channel blockers, amlodipine is a common one for high blood pressure. Diltiazem is another one. And then the thiazide-type diuretics in the United States by far and away, the most common is hydrochlorothiazide, although some of the others also work. So again, lots of choices, they’re cheap, they’re easily available. Doctors and nurses know how to use them ’cause they’ve been around forever. And so it’s a good list. And then there is, I’m not gonna show you, but there’s of course, 15 other categories of medicines that high blood pressure experts and others can use if you need more than three classes of medicine, although most patients do not. So then what happened, is soon after the guidelines came out, a big study was published, and I’ve already made reference to this, the SPRINT Study. This was the one with the robot in the dark room, measuring blood pressure. It was a really well done study. It was at almost 10,000 men and women. They were over age 50. They had a predesignated group that were over age 75. So it was well done. To get into the study you needed a blood pressure over 130, which was fine, and you needed to have a high cardiovascular risk. And I’ll explain that more in a moment, but it’s an important part of this conversation. Interestingly, they did not accept people with diabetes into the SPRINT Study. And that was a little bit puzzling, unless you knew that in the year or two before the SPRINT Study was being planned, there had been another big study funded by the National Institutes of Health, so a very well done, randomized trial that compared 140 versus one 120, the two blood pressures, in patients with diabetes to see which was better, and there was no difference. And so the conclusion was that 140 was as good as 120, and of course that made it much easier to treat patients ’cause again, it was one or two less medications. Each medicine lowers your blood pressure about 10 points or so on average. So 20 points is a couple of meds. So that was sort of weird because we already knew that in diabetes, it didn’t make any difference, but they were doing the study again, but had to exclude patients with diabetes. So it was a little bit funny the way that played out. But it does mean that the results of the study do not apply to patients with diabetes. Who of course are one of the groups of patients for whom treatment of high blood pressure is most important ’cause they’re at high risk of strokes, heart attacks, kidney disease, and so on. They compared people to get, they randomize people to 120 or 140 similar to the diabetes study. It took an extra medicine to get people under 120. And it turned out it was hard to get people under 120. The average was actually 121, which means on average, about half the patients couldn’t get below 120, even though they were getting free medicine, being seen by their clinician regularly more frequent than you would see someone in a normal clinical practice and so on. So that was interesting. Also that people couldn’t actually get less than 120, especially this cohort of somewhat older patients. And this is the diabetes study. I won’t go over it in detail, but again showed that there was no difference between 120 and 140 before the SPRINT Study. Now, the SPRINT threw us a curve ball because the results were positive, that is to say when they looked at all the events associated with high blood pressure, that is stroke, heart attack, non-fatal stroke and heart attack, death from stroke and heart attack, it turned out that there were less events in the group that was treated to 120. So this was a positive study suggesting that 120 was better than 140. But this was a little counterintuitive ’cause we already had six or seven studies that I showed you 10 slides ago that said, it didn’t really matter. We had this big diabetes study that said it didn’t matter, but here was this new study that said it matters. And then the hooker was that it also led to less mortality that people died less so often at 120, then one 140. So this created two different conversations. So there’s a group of people who thought that SPRINT was the end all, and that affected the way you look at this. Other people looked at this is an unexpected result. We’re not sure what it all means. And the conversation continued and got louder. There were a lot of side effects on the SPRINT Study. These were things they looked at carefully in advance. There was 67% more risk. And these were serious side effects. The criteria for this was side effects that the clinician thought was serious enough to send the patient to the emergency department or might be life threatening. That was the way the criteria was defined. So these are real low blood pressure. 67% more syncope, that is passing out, losing consciousness, a third more of blood chemistry abnormalities, a third more and kidney problems, two thirds more. So there were a lot of side effects, but nonetheless, the overall effect was beneficial. And it’s a little hard to explain the concept here, but there’s something in medicine when you think about a lot, which is called the number needed to treat. And I’ll show you this graphically in a couple of slides, but basically it’s a way to put the odds of you personally benefiting from an intervention. So remember these studies are in populations of patients, but now you and I are sitting across the table deciding what to do for you. And so what’s the likelihood that you will benefit given what we know about these populations that benefit? You’re with me on this? It’s a confusing subject, but it’s a way to put some numbers on the concept of better versus worse, and quantitated so that people can make individual decisions. And I’ll show you this graphically, it’ll be clear in a minute. But in general, the number needed to treat was about roughly a hundred, depending on what you’re measured over three years. So that’s about 300 over the course of any one year. So it means that if you and I are sitting across the table from each other, the odds are 299 to one that you’re not the one that’s gonna benefit. You’re with me on this? So the population benefits, but you may not. In fact, the odds are you won’t. And that’s just the way medical science works. Similarly, the number needed to harm is about the same. So we get some benefit, we get some harm and you’ll have to decide for you, which is better. Now, of course, in the way this study was done, the benefits are better than the harms, right? The benefit included heart attacks, strokes, and death. And the harms, the harms are things like feeling lightheaded and falling down and having an abnormal blood test. So they’re not the same, but it is worth noting that the frequency was similar. These are all comments I’ve already made. And the last bullet though, is that when you look at how the SPRINT Study applies to the community at large, to all of you, statistically, they’re only about one out of six of you that would meet the criteria to have been a subject in the SPRINT Study. In other words, whether it’s age or other diseases or what your cardiovascular risk was, whether you had diabetes, all those things were factors that determine whether you can enter the study or not, and only one out of six patients with high blood pressure were able to enter the study. So again, the generalized stability to the community at large is modest. And here are some of the risk factors. And so there was no one who had diabetes, no one with stroke, no one was frail, and no one who was, let’s just say under age 50. And as I mentioned, there was free care, frequent visits and so forth. And this very careful measurement that was lower than the usual measurement, if you remember. Then the other thing that was really important to know is that these were very high risk patients and that many of you have probably gone to websites and measured your 10-year risk of cardiovascular disease, of having a stroke or a heart attack. There’s a very good one on the Mayo Clinic, it’s called the Mayo Clinic Statin Decision Site. If you just Google Mayo Clinic Statin, it comes up, and you can put in your various risk factors and calculate your 10-year risk. And we use it in clinical practice a lot to decide who needs a statin drug for them for their risk. But it’s also relevant in this conversation about high blood pressure. And in fact, to enter this study, you needed a 10-year risk of 15%, and in fact, most people had 20%. If you’ve had a heart attack, your risk of having an event in the next 10 years is 20%. So 20% is a high number in this conversation. It’s like, you’ve already had a heart attack. And so these are people who are on the fairly far along spectrum of risk of cardiovascular disease. And here’s a cartoon. It doesn’t project super well, but what this is trying to say is bring to life that concept of number needed to treat. And what I mean by this is, so each little gray box represents one person. And if we have, say on the left hand side here, a thousand people, we can show who are then treated for three years to a blood pressure goal of 120, rather than 140, based on the data from the SPRINT Study. We know that 16 of them will not have a heart attack or stroke in the three year period. It’s the same as the number needed to treat. I’ve just done some arithmetic and made it a cartoon. But the point of this, the way to think of this, again, if you think about odds, if you started as one of the gray people, the vast majority of the gray people stay gray after three and a half years of being on two and a half medicines, right? Only a very small number become blue. And that’s that idea that what happens in populations is different than what happens in an individual patient. You’re with me? So this is a very intriguing way to think about medical interventions. And you can do this kinda chart with anything. And we do it with cholesterol, we do it with a lot of cardiovascular management, but you can do this with lots of other things. So if you have pneumonia from pneumococcal disease, and I give you penicillin, almost every one of you, maybe 80% of you will get better, right? So the number of boxes, this would all be blue. If this were talking about pneumonia and penicillin, but now we’re talking about treatment of a risk factor to prevent events over a period of time. And the number of people benefit one by one is much less. And so this is an important concept. And again, just to balance it, almost an equal number were harmed. Although to be fair, the benefits are more important than the harms, but the harms are real. And again, take home point here, most people started gray and stay gray. Very few people change as a result of this intervention, even though everyone has to take the medication. All right, so let me close this part of the conversation and we can then take some questions. The long and the short of it is this study came out and then started and has continues to this day, a debate in the medical community about what to do. And so the cardiologist took this study and came out with some guidelines that said, I’ll show you them in a minute, we should follow these guidelines. And then just around the same time, the primary care community, the internal medicine community and the family medicine committee looked at the guidelines and said, you know, actually we like the Joint National Commission guidelines. We like 150 if you’re over age 60, for everyone else 140, But the cardiologists said something totally different. They said that if it’s over 130, you should be treated, 140 everyone should be treated and 130, if you’re at high risk. And that anyone over 120, we would call an elevated blood pressure. So it totally changes the conversation from 140 to 120 based on the results of this one big study. And so these are what their recommendations are for treatment, basically saying if you’ve already had a heart attack, then we should treat you using 130 as the cut point. If you’re at very high risk of having a heart attack, we should treat you at 130, and if you’re at lower risk, less than 10%, then 140 is okay. And so that’s now the debate. We have the 130 and 140 school, and we have the 140 and 150 school. And we’re all just caught in the middle, and we have two groups of really smart people looking at the same studies and drawing completely different conclusion. Now, to try to sort this out, there’ve been a couple of studies of late. There was one just published this week. I don’t have a slide from, but it’s consistent sort of with what I’m gonna show you. But this was a very nice study that was published this year that looked at all of the studies of high blood pressure, was 70 different studies, 300,000 patients, included men and women 60 years old. And basically they tried to answer the question of, does it matter what the blood pressure is when you start, when you start treatment. And basically they looked at all the studies and they said, and the star here, the asterisk means that the results are significant. And what they showed is that if your blood pressure is over 160 and you treat it, treatment works. There’s a 7% reduction in mortality and a 22% reduction in cardiovascular events. So everyone agrees with that. If it’s over 160, it should be lowered. 140 to 160, this study showed it works. So if it’s over 140, it works. I will note there was a paper published this week that just showed even between 140 and 160. It’s not so clear that it works. (audience laughing) If it’s less than 140, it doesn’t work. So even though blood pressure becomes a risk factor at low levels, if you’re less than 140 when you treat it, you don’t get any benefit from that treatment according to these 70 studies. So over 160 it works, over 140 it works, although now we have a little debate there, but under 140, it doesn’t work with the one possible exception in people who have heart disease. CHD stands for coronary heart disease. So if you already have had a heart attack, then it’s reasonable to treat at 130, which is what the cardiology guidelines say. And then what happened after this conversation is that the family physicians independently in the internist, again, looked at their data and all the recommendations they say, “Well, what do we think? “Are we gonna go along with the cardiology guidelines?” And they both said no. So we’re gonna stick to the guidelines we published a couple of years ago, and still stick with a 150 if you’re over age 60 or 140 for most patients. It’s also worth noting that if you use 120, if use the guidelines that the cardiology guidelines suggest that half the population is now labeled as having hypertension. And you know, that just doesn’t have face validity, right? It doesn’t make sense that all of us would be sick. – [Man] 46 means I’ll act like a (indistinct). (laughing) (audience laughing) – That half the population would be hypertensive. So my final thoughts, and then we’ll open it up. We talked about measuring blood pressure differently in the office, with carefully following the 19 guidelines. I would say if you’re a patient in an office like that, you should ask the clinician to retake your blood pressure if the first measurement is high. Sometimes it’s not feasible to do that out where the medical assistant took the blood pressure. But maybe when you get in to see your personal clinician, that would be a time to have the blood pressure taken again in a close to correct method as possible. I think it’s excellent to do home monitoring, Get a good machine, something that fits over the arm, don’t play with the wrist fingers and so on. Make sure it covers your arm the way the dimensions are supposed to. Many of you will need a large size cuff, which takes an extra conversation with who’s ever selling you the machine, and then sit comfortably, have your arm be unclothed and so on, as we discussed before you take it. Take it before breakfast, before your medications, and take it before dinner. Consider ambulatory monitoring for those who are in a toss up zone you’re just not sure what to do, especially after this talk. And so an ambulatory monitor is a excellent tie-breaker. Gives you another complete, relatively inexpensive, totally safe and noninvasive way to collect information. And look at your cardiovascular risks. So you would be doing this anyway, if you’re interested in preventing heart disease or stroke with the use of aspirin or statins, ’cause we make those decisions based on your risk, and what this literature now suggests is that we should be using that risk prediction to help decide who should be on blood pressure pills too. And if you’re really low risk, then the benefit for you may be a very high number needed to treat. In other words, it may not be worth it to you to take the medications. And again, then it depends on side effects and preferences and costs and so on. I think 140//90 is a reasonable compromise these days. I think, although this new paper, again, questions, whether that’s maybe too low, but nonetheless, I think most of the literature would suggest that for most people, 140/90 is a good number at which we begin treatment, but make sure that is taken correctly. ‘Cause if it’s falsely elevated then way too many people will be treated. 150/90 is probably fine for a lot of low risk, older, over age 60 people, not so old. But over age 60, to be between 140 and 150 is not the end of things. It’s fine if especially if you’re having side effects, don’t wanna take a third medicine say or whatever, that may be fine for a lot of people, especially if your overall risk is low or whatever your personal preferences are given that gray box diagram that I showed that you may not be the one who benefits. And for those who are very high risk, especially those with bad heart disease treating less than 130/80 may make sense. If you’re in that situation, you’re probably seeing a cardiologist already anyway, and it will be their preference to treat you to 130/80. And that’s okay. ‘Cause that’s where the evidence is strongest. And again, you shared decision making. What we mean by this is that try to understand the numbers as well as you can. Health literacy is complicated, and this is what we call health numeracy, which is understanding the numbers, which is even more complicated. But if you’re inclined that way and have a clinician who’s willing to the numbers or point you to a good website, then it’s worth thinking about it. And you given the number needed to treat and the uncertainty here, I think it would be incorrect for clinicians to be dogmatic. And so I think your preferences about this rule the day. And what we’ve learned particularly strongly off late is that using team approaches are very effective. And some of the big systems like Kaiser Northern California and others have done a terrific job controlling blood pressure in their population with some innovative strategies that really rely on non-physicians particularly helping to manage blood pressure, but it also includes careful measurements so that people aren’t mislabeled. So with that I’ll thank you and stop and leave plenty of time for questions. Thank you very much. (audience clapping) Yes, the question is where does stroke and atrial fibrillation come in? Well, the easiest thing to say is that in the causative relationship, high blood pressure is a risk factor for producing both. So we definitely know that people with hypertension and elevated blood pressure are a greater risk for stroke and also greater risk for atrial fibrillation. Atrial fibrillation, the medicines we use to control atrial fibrillation often do double duty as blood pressure pills. So some of the calcium channel blockers, beta blockers, things like that. And so it’s not in clinical practice. It’s usually not that big a conversation ’cause you already need those medicines to control your heart rate since that’s one of the ways they work. But for stroke, we do recommend tighter control, but 140 is probably fine, you don’t have to go to 130, ’cause there is a little bit of risk of being too low for some of these diseases as well. And so 140’s probably the right way to go for both atrial fibrillation and stroke. And very importantly, although this is more your clinicians issue, is when you’re in the hospital with a stroke, we let the blood pressure ride very high. And we’ve learned that treating it too soon can be quite dangerous. So that’s a little counterintuitive, but if you wander the halls of the neuro intensive care unit here, you’ll see people with blood pressures routinely over 180, 190 and so forth. That’s just when they’re in the hospital during the acute stroke. As they come out over the course of four to six weeks or whatever, then we begin to begin to treat it with a goal of getting less than 140 for sure If they have concurrent heart disease, then we go to 130. So the question was in the grid with the number needed to treat. The harms were low blood pressure, syncope, blood tests, abnormalities, and kidney abnormalities. So they were all pre-designed side effects that were thought serious enough to send the patients to the hospital to be evaluated. But so they’re serious, but they’re not like having a heart attack or a stroke or dying, you know? So that’s when I say they’re serious, but not as serious as the benefits. (indistinct) Yes, there are medicines that can cause high blood pressure, the most important are illegal ones. (audience laughing) Yeah. So methamphetamine and cocaine are two on the short list, some of the other derivatives in that category, such as a pseudoephedrine that people take sometimes for respiratory congestion, phentermine, which is a weight loss drug that I don’t recommend can raise your blood pressure. And there are a handful of others. Well, that depends. So the comment was about prostate medicine. The most common prostate medicine actually lowers your blood pressure. It’s a class of medicines, in fact that we used to use to treat high blood pressure. So that would be an unusual circumstance, But yeah, let’s see, sir. Is very low blood pressure a risk factor. – [Man] And at what level? – Yeah, that’s controversial. If you were gonna draw the relationship between ill health and blood pressure on a curve, the shape of the curve is so ill health would be on the Y axis, your blood pressure’s on the X axis. The shape of the curve in many studies is a J, that is to say that the lowest blood pressures are associated with poor outcomes. Now that’s a little bit confusing because some of the people in those kinds of studies are sick. And so if you’re frail and at the end of life and your blood pressure’s coming down, that may account for some of that J. But the current concern is that it also may increase the risk of heart attacks, that you need a certain blood pressure to fill the vessels that supply the heart when the heart is relaxing, so called diastole. And so there is a concern about that, is not proven. The studies have yoyod a little bit over the course of the last several decades, but it is a concern that over-treatment, or at least in Denovo, without treatment people with lower blood pressures may well be at increased risk. And in the treatment studies, if you treat too low, there may be an increased risk of heart attack and at risk patients. And so that is one of the concerns. And that’s why you saw that people were passing out with the aggressive treatment. They weren’t having more heart attacks though in that study. So the literature is mostly reassuring, but there has been a concern circulating in the scientific community that may be too low, can increase the risk of heart attacks. But in many heart conditions like heart failure, we treat people very low and that’s for a different reason, that’s to allow the heart to function, to pump better. So that’s a different conversation. So there are different circumstances where we would strategically aim for low. But for specifically a coronary artery disease, there’s this concern. But again, the SPRINT Study was reassuring in that regard, there was no increased risk of heart attack in the low group. In fact, they had less heart attacks. So the current thinking is probably okay, and especially if it’s your second number, that’s really low. So sometimes especially as people get older, the blood vessels get stiff. And so the upper number may be high and you have systolic high blood pressure, but the lower number is really low, like 60 or 40, or maybe it just keeps, it never goes, you know, you can’t record any number. And that’s okay. As far as we think that that’s okay, that’s not associated with increased risks. But it has been in the literature as a concern. But the current thinking is it’s probably not a problem. So the question is, is there any evidence about which class of drugs is better for any specific patient? And if you go back in the history of the Joint National Commission Recommendations over the years, there’s been a wide variety… There was several iterations where thiazides were best for everyone. So I used to tell the residents, everyone should be started on a thiazide. And then the literature changed a little bit and it became thiazides or beta blockers. So then I would say to the residents, well, thiazides should be first or second. You could start with beta blockers you could start with thiazides. Now we have three other drugs. So now we say, thiazides need to be in the top three. So the recommendations have changed. As you notice, beta blockers are off the list because we think they don’t work as well to prevent stroke. The prostate medicines are off the list because they’re inferior to other classes of blood pressure pills. And in African Americans there’s monotherapy, the ACE inhibitors and ARBs don’t work as well. But the other studies… There is a literature out there of monotherapy, you know, which drug is better at the start, but that’s sort of a silly question because most people end up as they age anyway, and needing more than one drug. And so it doesn’t really matter what you start with, ’cause everything works. And it’s really more about side effect, profile costs, formulary preferences, and so on. So if thiazide makes you urinate and that’s a problem for you, then that’s not a good drug for you. And it doesn’t matter whether it’s two millimeters better than the other one or not. Or if ACE inhibitors cause your potassium to go too high, then that become a more dominant question than whether it’s two millimeters better or for worse But in general, the main thinking is that in African-American’s, there is a class preference based on race. But if for everyone else it’s thought to be neutral and that’s why you get the smorgasbord of four classes. So there is a literature on that, but it’s probably not worth concerning about it and the guidelines have ignored that literature, basically discounted it. So the question is, if home measurement is low and your office measurement is high, is it a measurement error or is it white coat hypertension? The answer is we don’t know. And so what you wanna do is either thoughtfully look at the cuff you purchased, or what I would recommend to a patient is to bring the cuff in and we’ll do it together and see what the story is. But sometimes the cuffs are just too small. The single manometers in the office are maintained carefully. The digital measurements that many of the offices use are as good as the mercury sphygmomanometer, if they’re maintained correctly. And the home measurement tools can be as well, especially if it’s a standards sphygmomanometer. But, you know, things need to be maintained, so a cuff that ages may lose its accuracy and- – [Man] Quite brand new when it was. – Consumer reports does review these and I won’t favor any one machine over another, but they do. And so they’re a good organization. I’d follow their recommendations. But I think the most valuable thing is to bring the cuff into the physician’s office and just compare. And that way you’ll get a chance to see how you’re doing. You know, if your measurement technique is good and if the equipment is good. And on that note, I’ll stop. I’ll stay take some additional questions upfront. Good evening, everyone. – Thank you. (audience clapping) (upbeat music)

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