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

thiazide first, second or third with calcium channel blockers for a second or third. This is how the modern menu was ordered. And that again was good for the patients, because there were a lot of drugs in these classes, good for the doctors, because they are drugs that we knew how to use. You will or may notice that one class of medication that is not on this list is beta blockers. And beta blockers have been used for

high

blood

pressure

for many, many years; They are very good for other conditions. But when compared to these four medications, they are not as effective as a single therapy.

But that's a little misleading because they're great as a third or fourth drug or they're great if you need them for something else. So it still

lower

s

blood

pressure

, but it's not as evidence-based in terms of stroke prevention in particular as these other four classes of medications. But it's still on the list, we use it all the time. It is a very effective way to

lower

blood pressure, but not as a first or second drug as a primary blood pressure lowering treatment. And something that not everyone knew, even though it's been in the literature for several decades, is that ACE inhibitors and angiotensin receptor blockers don't work as well in African Americans as the other classes of medications.

So they specifically went all out and said that for African Americans we recommend thiazides or calcium channel blockers first. Again, this is also a little misleading because many patients need, most patients need, more than one medication. And again, once you get to drug number three, you'll start going back to RCTs and ARBs very quickly in African Americans, but I would start with thiazide diuretics or a calcium channel blocker as your first-line drug. And in kidney disease, that's the only disease with specific recommendations, especially if you're spilling protein in your urine, so ACE inhibitors and ARBs have a long history of helping preserve kidney function.

But that actually applies more in the context of chronic kidney disease than in the case of simple essential hypertension. So those were the recommendations and we read this and said, okay, that's sensible. They asked the right questions and examined the right body of evidence. These are patient centered, good for primary care, everything was good. And then the sky fell. (Audience laughs) But these are the medications 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 can still recognize them because many of these medications have It has existed for decades.

They are all generic and cheap. They are in everyone's form, not necessarily everyone in each category, but one of each category is in everyone's form. That's why it's pretty easy to find an ACE inhibitor that works. An enalapril or lisinopril are quite common. Angiotensin receptor blockers. Losartan is probably the most common. Valsartan is the one that had a bit of imperfections in the synthesis. That's been out of circulation lately, but there are others in that class. Calcium channel blockers, amlodipine, are common for

high

blood pressure. Diltiazem is another. And then the thiazide diuretics in the United States, by far the most common is hydrochlorothiazide, although some of the others work as well.

Again, there are many options, they are cheap and easily available. Doctors and nurses know how to use them because they have always been around. And so it's a good list. And then there are, I'm not going to show you, but there are, of course, 15 other categories of medications that high blood pressure experts and others can use if you need more than three classes of medications, although most patients don't need them. . So what happened is that shortly after the guidelines were published, a large study was published, and I've already referenced it, the SPRINT Study. This was the one with the robot in the dark room, measuring blood pressure.

It was a really well done study. There were almost 10,000 men and women. They were over 50 years old. They had a pre-designated group that was over 75 years old. So it was well done. To participate in the study you needed a blood pressure over 130, which was fine, and you needed to be at high cardiovascular risk. And I'll explain it 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 disconcerting, unless you knew that in the year or two before the SPRINT Study was planned, there was another large study funded by the National Institutes of Health, so a very well done randomized trial was done that compared 140 versus 120, both blood pressures, in patients with diabetes to see which was better, and there was no difference.

So the bottom line was that 140 was just as good as 120, and of course that made it a lot easier to treat patients because again, it was one or two less medications. Each medication reduces blood pressure by about 10 points on average. So 20 points is a couple of medications. That was a little strange because we already knew that there was no difference in diabetes, but they were doing the study again, but they had to exclude the patients with diabetes. So it was kind of funny the way it played out. But it does mean that the study results do not apply to patients with diabetes.

Who, of course, are one of the groups of patients for whom high blood pressure treatment is most important because they are at high risk of strokes, heart attacks, kidney diseases, etc. They compared people and randomly assigned them to 120 or 140, similar to the diabetes study. An extra drug was needed to get people below 120. And it turned out that it was difficult to get people below 120. Actually, the average was 121, which means that, on average, about half of the patients they couldn't go below 120, even though they were under 120. get free medications, be seen by their doctor more often than they would see someone in a normal clinical practice, etc.

So that was interesting. Also, people couldn't get less than 120, especially this cohort of somewhat older patients. And this is the study of diabetes. I won't go over it in detail, but again I 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, 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 cerebral. and heart attack, it turned out that there were fewer events in the group that was treated with 120.

So this was a positive study that suggested that 120 was better than 140. But this was a little contradictory because 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 does matter. And then the funny thing was that also leading to lower mortality was the fact that people died less frequently at age 120, and then at age 140. So this generated two different conversations. So there's a group of people who thought SPRINT was the end all be all and that affected the way this is viewed.

Other people saw this as an unexpected result. We're not sure what this all means. And the conversation continued and grew louder. There were many side effects in the SPRINT study. These were things they observed carefully beforehand. There was a 67% higher risk. And these were serious side effects. The criteria for this were side effects that the doctor deemed serious enough to send the patient to the emergency department or that could be life-threatening. This is how the criteria were defined. So it's really low blood pressure. 67% more syncope, that is, fainting, loss of consciousness, a third more abnormalities in blood chemistry, a third more and kidney problems, two thirds more.

There were many side effects, but still the overall effect was beneficial. And it's a little difficult to explain the concept here, but there is 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 increase the odds that you will personally benefit from an intervention. Remember that these studies are done in patient populations, but now you and I are sitting on the other side of the table deciding what to do for you. So what is the likelihood that you will benefit given what we know about these populations that benefit?

Are you with me on this? It's a confusing topic, but it's a way to put some numbers on the concept of better versus worse, and quantify them so people can make individual decisions. And I'll show you this graphically, it will be clear in a minute. But in general, the number needed to treat was approximately one hundred, depending on what was measured over three years. That's about 300 over the course of a 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 won't be the one who will benefit.

Are you with me on this? So the population benefits, but you may not. In fact, chances are you won't. And that's how medical science works. Similarly, the number needed to damage is approximately the same. So we get some benefit, we get some harm, and you'll have to decide for yourself what's better. Now, of course, the way this study was conducted, the benefits outweigh the harms, right? The benefit included heart attacks, strokes and death. And the harms, the harms are things like feeling dizzy, falling, and having an abnormal blood test. So they are not the same, but it is worth noting that the frequency was similar.

These are all comments I have already made. And the last point, though, is that when you look at how the SPRINT Study applies to the community at large, to all of you, statistically, only one in six of you would meet the criteria to have been a subject in the SPRINT Study. . In other words, whether it was age or other diseases or what your cardiovascular risk was, whether you had diabetes, all of those things were factors that determined whether you can enter the study or not, and only one in six patients with high blood pressure was be able to enter the study.

Again, overall stability for the broader community is modest. And these are some of the risk factors. So there was no one who had diabetes, no one who had a stroke, no one who was frail, and no one who was, say, under 50 years old. And as I mentioned, there was free care, frequent visits, etc. 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 many of you probably went to websites and measured your 10-year risk of cardiovascular disease, of having a stroke or a heart attack.

There's a really good one at Mayo Clinic, it's called the Mayo Clinic Statin Decision Site. If you just Google Mayo Clinic statins, it will come up and you can enter your various risk factors and calculate your 10-year risk. And we use it a lot in clinical practice to decide who needs a statin based on their risk. But it's also relevant to this conversation about high blood pressure. And in fact, to participate in this study, you needed a 10-year risk of 15%, and in fact, most people had 20%. If you have 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. Therefore, these are people who are in a fairly advanced spectrum of risk for cardiovascular disease. And here is a cartoon. It doesn't project very well, but what it's trying to say is to bring to life the concept of number needed to treat. And what I mean by this is that each little gray box represents a person. And if we have, let's say on the left side, a thousand people, we can show who is treated for three years with a blood pressure goal of 120, instead of 140, based on data from the SPRINT study.

We know that 16 of them will not have a heart attack or stroke over the three-year period. It is the same number necessary to treat. I just did some arithmetic and turned it into a cartoon. But the point of this, the way to think about this, again, if you think about the odds, if you started out as one of the gray people, the vast majority of gray people are still gray after three and a half years of being in two . and a half of medicine, right? Only a very small number turn blue. And that is the idea that what happens in populations is different from what happens in aindividual patient.

You are with me? This is a very intriguing way to think about medical interventions. And you can make this type of graph with anything. And we do it with cholesterol, we do it with a lot of cardiovascular control, but you can do this with many other things. So if you have pneumonia from pneumococcal disease and I give you penicillin, almost all of you, maybe 80% will get better, right? So the number of boxes, they would all be blue. If this were talking about pneumonia and penicillin, but now we're talking about treating a risk factor to prevent events over a period of time.

And the number of people who benefit one by one is much smaller. And so this is an important concept. And again, to balance it out, almost an equal number were harmed. Although to be fair, the benefits outweigh the harms, but the harms are real. And again, you have to remember that most people started out gray and stay gray. Very few people change as a result of this intervention, even though everyone has to take the medication. Alright, let me close this part of the conversation and then we can answer some questions. Long story short, this study arose and then began, and continues to this day, a debate in the medical community about what to do.

And then the cardiologist took this study and came up with some guidelines that said, I'll show you in a minute, we need to follow these guidelines. And then, around the same time, the primary care community, the internal medicine community, and the family medicine committee looked at the guidelines and said, we actually like the Joint National Commission guidelines. We like 150 if you're over 60, for everyone else 140, but the cardiologists said something totally different. They said that if it is greater than 130 it should be treated, 140 should be treated for everyone and 130, if you are at high risk. And we would call that high blood pressure in anyone over 120 years old.

So it totally changes the conversation from 140 to 120 based on the results of this great study. And these are their recommendations for treatment, they basically say if you've already had a heart attack, then we should treat it using 130 as a cutoff. If you have a very high risk of having a heart attack, we should treat you at 130, and if you have a lower risk, less than 10%, then 140 is fine. And that is now the debate. We have school 130 and 140, and we have school 140 and 150. And we're all stuck in the middle, and we have two groups of really smart people looking at the same studies and coming to completely different conclusions.

Now, to try to figure this out, a couple of studies have been done lately. One was just published this week. I don't have a slide, but it's consistent with what I'm going to show you. But this was a very good study that came out this year that looked at all the studies on high blood pressure; There were 70 different studies, 300,000 patients, including men and women aged 60 years. And they basically tried to answer the question of whether it matters what your blood pressure is when you start treatment. And they basically looked at all the studies and said, and the star here, the asterisk, means the results are significant.

And what they showed is that if your blood pressure is over 160 and you treat it, the treatment works. There is a 7% reduction in mortality and a 22% reduction in cardiovascular events. So everyone agrees with that. If it is higher than 160, it should be lowered. 140 to 160, this study showed that it works. So if it is greater than 140 it works. I will note that there was an article published this week that even showed between 140 and 160. It's not so clear that it works. (Audience laughs) If it's less than 140, it doesn't work. So although blood pressure becomes a risk factor at low levels, if you're under 140 when you treat it, you don't get any benefit from that treatment according to these 70 studies.

So above 160 it works, above 140 it works, although we now have a little debate about it, but below 140 it doesn't work, with the only possible exception being people who have heart disease. CHD means coronary heart disease. So if you've already had a heart attack, then it's reasonable to treat it at 130, which is what the cardiology guidelines say. And then what happened after this conversation is that the family doctors, independently, at the internist, again, looked at their data and all the recommendations and said, "Well, what do we think? "Are we going to follow the guidelines? of cardiology?" And they both said no.

So we'll stick to the guidelines we published a couple of years ago, and stick with 150 if you're over 60 or 140 for most patients. It's also worth noting that if you use. 120, if we use the guidelines that the cardiology guidelines suggest, half the population is now labeled as hypertensive. And you know, that just has no face validity, right - 46 means I'm going to act like (incomprehensible). (laughs) (audience laughing) - That half the population would be hypertensive. So, my final thoughts, and then we will talk about measuring blood pressure differently in the office, carefully following the 19 guidelines. That if you are a patient in an office like that, you should ask the doctor to take your blood pressure again if the first measurement is high.

Sometimes it is not possible to do this at the place where the medical assistant took the blood pressure. But maybe when you visit your personal doctor, that's the time to take your blood pressure again as correctly as possible. I think it is excellent to do monitoring at home. Get a good machine, something that fits your arm, don't mess with your wrist fingers, etc. Make sure it covers your arm the way the dimensions are supposed to. Many of you will need an oversized cuff, which requires an additional conversation with whoever sells you the machine, and then sitting comfortably, stripping your arm, etc., as we discussed before putting it on.

Take it before breakfast, before your medications, and before dinner. Consider outpatient follow-up for those who are in an at-risk area and are unsure what to do, especially after this talk. Therefore, an ambulatory monitor is an excellent tiebreaker. It offers you another complete, relatively inexpensive, totally secure and non-invasive way to collect information. And watch 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, because we make those decisions based on your risk, and what this literature suggests now is that we should use that risk prediction to help decide who should also take blood pressure pills.

And if your risk is really low, then the benefit to you may be a very high number needed to treat. In other words, the medications may not be worth taking. And again, it depends on side effects, preferences, costs, etc. I think 140//90 is a reasonable compromise these days. I think, although this new article, again, questions whether it's maybe too low, I think most of the literature would suggest that for most people, 140/90 is a good number to start treatment with, but make sure it is taken correctly. Because if it is falsely elevated, too many people will be treated. 150/90 is probably fine for many low-risk people, older, over 60, and not so old.

But after age 60, being 140 to 150 is not the end of things. It's okay if, especially if you have side effects, you don't want to take a third medication, let's say or whatever, that may be okay for a lot of people, especially if your overall risk is low or whatever your personal preferences are, given those grays. boxplot I showed that you may not be the one to benefit. And for those who are at very high risk, especially those with serious heart disease, it may make sense to treat less than 130/80. If you're in that situation, you're probably already seeing a cardiologist anyway, and their preference will be to treat you at 130/80.

وهذا جيد. Because that's where the evidence is strongest. And again, you shared the decision making. What we mean by this is, try to understand the numbers as best you can. Health literacy is complicated, and this is what we call health numeracy, which is understanding numbers, which is even more complicated. But if you're that inclined and you have a doctor who's willing to crunch the numbers or point you to a good website, then it's worth thinking about. And given the number needed to treat and the uncertainty here, I think it would be wrong for doctors to be dogmatic. And so I think your preferences on this rule of the day.

And what we have learned particularly strongly lately is that using team approaches is very effective. And some of the big systems like Kaiser Northern California and others have done a great job of controlling blood pressure in their population with some innovative strategies that really rely on non-medical people to particularly help control blood pressure, but also include careful measurements to that people are not mislabeled. With that I will thank you and stop and leave plenty of time for questions. شكرا جزيلا لك. (Audience applauds) Yes, the question is where do strokes and atrial fibrillation come in? Well, the easiest thing to say is that in the causal relationship, high blood pressure is a risk factor for producing both.

So we definitely know that people with hypertension and high blood pressure have a higher risk of stroke and also a higher risk of atrial fibrillation. Atrial fibrillation, the medications we use to control atrial fibrillation often do double duty as blood pressure pills. Some of the calcium channel blockers, beta blockers and things like that. And that's why it doesn't happen in clinical practice. It's usually not that big of a conversation because you already need those medications to control your heart rate since that's one of the ways they work. But for stroke, we recommend tighter monitoring, but 140 is probably fine, you don't need to go to 130, because there is a small risk of being too low for some of these diseases as well.

So 140 is probably the right way to go for both atrial fibrillation and stroke. And the most important thing, although this is more of a doctors' problem, is that when you're in the hospital with a stroke, we let your blood pressure get too high. And we've learned that treating it too soon can be quite dangerous. That's a little counterintuitive, but if you walk the halls of the neurointensive care unit here, you'll see people with blood pressure routinely over 180, 190, etc. That's right when they are in the hospital during the acute stroke. As they come out over the course of four to six weeks or whatever, we start treating it with the goal of getting under 140 for sure.

If they have concurrent heart disease, then we go to 130. So the question was on the grid with the number needed to treat. The damages were low blood pressure, syncope, blood tests, abnormalities and kidney abnormalities. Therefore, they were all pre-designated side effects that were considered serious enough to send patients to the hospital for evaluation. But they're serious, but they're not like having a heart attack or a stroke or dying, you know? That's when I say they are serious, but not as serious as the benefits. (incomprehensible) Yes, there are medications that can cause high blood pressure, the most important of which are illegal ones. (audience laughing) Yeah.

So, methamphetamine and cocaine are two on the short list, some of the other derivatives in that category, like pseudoephedrine that people sometimes take for respiratory congestion, phentermine, which is a drug to lose weight which I do not recommend, it can raise the blood. pressure. And there are a handful of others. حسنا ذلك يعتمد. So the comment was about prostate medications. The most common prostate medication actually lowers blood pressure. In fact, it is a class of medications that we used to use to treat high blood pressure. So that would be an unusual circumstance, but yes, let's see, sir. Is very low blood pressure a risk factor? - And at what level? - Yes, that is controversial.

If you were to draw the relationship between poor health and blood pressure on a curve, the shape of the curve is such that poor health would be on the Y axis, your blood pressure would be on the many studies is a J, meaning lower blood pressures are associated with poor outcomes. That's a little confusing because some of the people in those types of studies are sick. So if you're frail and at the end of your life and your blood pressure is dropping, that may explain some of that J. But the current concern is that it may also increase the risk of attackscardiac, you need a certain blood pressure to fill the vessels that supply the heart when it relaxes, which is called diastole.

And so there is a concern about it, it is not proven. Studies have varied somewhat over the past few decades, but it's concerning that with overtreatment, or at least in Denovo, without treatment, people with lower blood pressure may be at higher risk. And in treatment studies, if the treatment is too low, there may be an increased risk of heart attack and patients at risk. And that is one of the concerns. And that's why you saw people faint with the aggressive treatment. However, in that study they did not have more heart attacks. So the literature is mostly reassuring, but concerns have circulated in the scientific community that it may be too low and may 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: to allow the heart to work and pump better. So that's a different conversation. Therefore, there are different circumstances in which we would strategically target low levels. But there is this concern specifically for coronary artery disease. But again, the SPRINT study was reassuring in that sense: There was no increased risk of heart attack in the low group. In fact, they suffered fewer heart attacks. So the current thinking is probably fine, and especially if it's your second number, it's really low.

Sometimes, especially as people age, blood vessels become stiff. So the top number may be high and you have high systolic blood pressure, but the bottom number is very low, like 60 or 40, or maybe it just stays, never goes away, you know, no number can be recorded. وهذا جيد. As much as we think that's okay, it's not associated with increased risks. But it has appeared in the literature as a concern. But current thinking is that it's probably not a problem. So the question is: is there any evidence about which class of drug is best for a specific patient? And if you go back in the history of the Joint National Commission Recommendations over the years, there's been quite a variety...

There were several iterations where thiazides were better for everyone. So I used to tell residents that everyone should start taking thiazides. And then the literature changed a little bit and they became thiazides or beta blockers. So I would say to residents, well, thiazides should be first or second. You could start beta blockers or thiazides. Now we have three other drugs. So now we say that thiazides should be in the top three. So the recommendations have changed. As you may have noticed, beta blockers are off the list because we think they don't work as well at preventing strokes.

Prostate medications are off the list because they are inferior to other classes of blood pressure pills. And in African Americans there is monotherapy, ACE inhibitors and ARBs don't work as well. But the other studies... There's literature on monotherapy, you know, about which drug is better at first, but that's kind of a silly question because most people stop as they get older and need more than one drug. . And it doesn't really matter what you start with, because everything works. And it's really more about side effects, profile costs, form preferences, etc. So if thiazide makes you urinate and that is a problem for you, then it is not a good medication for you.

And it doesn't matter if it is two millimeters better than the other or not. Or if ACE inhibitors cause your potassium level to go too high, then that becomes a more dominant question than whether it's two millimeters better or worse. But overall, the main thought is that among African Americans, there is a class preference based on race. . But to everyone else it's thought to be neutral and that's why you get a smorgasbord of four classes. There is literature on that, but it's probably not worth worrying about and the guidelines have ignored that literature, basically thrown it out.

So the question is, if the home measurement is low and the office measurement is high, is it a measurement error or is it white coat hypertension? The answer is that we don't know. So what you need to do is take a good look at the bracelet that you bought, or what I would recommend to a patient is to bring it to them and we'll do it together and see what the story is. But sometimes the cuffs are too small. The individual pressure gauges in the office are carefully maintained. The digital measurements used by many offices are as good as the mercury sphygmomanometer, if maintained correctly.

And home measuring tools can be too, especially if it's a standard sphygmomanometer. But, you know, things need maintenance, so an aging bracelet can lose its precision and... It was pretty new when it was. - Consumer Reports reviews them and I won't favor any machine over another, but they do it. And so they are a good organization. I would follow your recommendations. But I think the most valuable thing is to take the bracelet to the doctor's office and just compare it. And that way you'll have 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 still answer some additional questions in advance. مساء الخير جميعا. - شكرا لك. (audience applauding) (upbeat music)