Stanford Doctor Discusses High Blood Pressure: What We Know Now and What We Need to Know

Thank you Donna for that kind introduction and thank you all for being here today. I imagine most of you are not basketball fans or have a working DVR at home, one of the two, so I have prepared some related slides. to

high

blood

pressure

related to current

know

ledge of the condition and then I have some slides related to things to look for in the clinic in the future. Hopefully in the next few years there will be about 36 slides where we can spend all our time on one. of slides or none of the time on all slides, it's totally up to you.

I think the format of this session is that I'm going to try to go through the slides and then at the end we'll save the questions for then, but if I digress or there's some clarification that you have right there and then it's okay if you want to ask at that time, that too Alright. I'll go ahead and get started. Oh actually, probably one point here, you have to give a lot of lectures. When you're at Stanford, I spent a lot of time on symbols, you'll see several symbols throughout this lecture. The two symbols I chose for this have to do with

what

we

know

now and

what

we should know for a hands-on demonstration for those in the audience how many people own or have a

blood

pressure

cuff at home that they use well, quite a few how many people have a smart watch that they use for anything well, not so many well, well, we'll get to those points as we go through the conference, so just for full disclosure, I'm on a couple of different scientific advisory boards that I've listed here.

The first one is for a company called Paramus that started with bioengineering here at Stanford and is a company. involved in making a sort of 21st century device for measuring blood pressure. I also advise a company called bio innovate Ireland that is also doing something similar in Ireland and then I am on the advisory board of a company that makes a drug related to kidney disease. called episode, so what we know now, I think it's important to start with some basic facts about

high

blood pressure and why we care, because for many years people didn't really care much, high blood pressure affects many people.

It affects about a third of the US population and more than half of all Americans who are 65 years old or older have high blood pressure, so it is quite common, what is perhaps more surprising is that more than Half of people who have high blood pressure do not have it under control, which is probably more so now than two years ago, when the target blood pressure we all aimed to achieve was lowered according to clinical studies and national guideline recommendations. In this lecture I am going to show some slides. I will show the results of a clinical trial, just a little bit of research data, but mainly I will talk about general concepts, but the concepts I will talk about from a research point of view relate to the actual blood pressure target number at the time. that we want to get to, so this is an important point that half of all people with this condition are not under control.

This matters to us because hypertension is a major risk factor for major, life-altering diseases. So what would those be so that we can think about the long-term consequences? hypertension related to several different organs, but I have tried to summarize here some of the most critical ones, so that high blood pressure can lead to heart disease which can be in the form of myocardial infarction or heart attack or in the form of high heart failure . Blood pressure can also cause brain disease which can be in the form of carotid artery disease or, in severe cases, stroke, and in long-term dementia, it has been associated with higher blood pressure.

High blood pressure is also associated with kidney disease in multiple ways and although I am a nephrologist. Today I'm going to talk about blood pressure, but right now I'll let you know that high blood pressure is both a cause of kidney disease and an aggravator of existing kidney disease. It is a consequence of kidney disease, so kidney disease and high blood pressure go hand in hand. High blood pressure can also damage blood vessels, so that may be relevant to heart disease, which may be relevant to carotid artery disease and stroke, but that may also be relevant to what we call arterial disease.

Peripheral disease, which you may have heard about in previous sessions of this health lecture series related to diseases of the blood vessels leading to the arms and legs, high blood pressure is also a critical factor. risk factor for diseases during pregnancy, so things like preeclampsia and premature birth are related to high blood pressure, so I have tried to list a number of conditions here. This isn't all-encompassing, but I tried to highlight some of the highlights like why we care about blood pressure and there are certainly acute consequences of high blood pressure and I didn't really cover them here, but what we're talking about here They are from the long-term risks of hypertension, so there is a lot to worry about, so what?

Shown here is a graph with blood pressure on the y-axis and one year of data spaced about a month apart on the x-axis. The top line is the systolic blood pressure and the bottom line is the diastolic blood pressure, so that's something like that. the upper and lower limit, if you will, of blood pressure and the arrows refer to different time points when something happened to this individual at the bottom and I don't know if this will appear in the video, but I'll try along the Down here, we happen to have a pointer or that doesn't translate very well into video format.

Well, that's me. I'm going to stick my hand in here just for a second. These two terms here are electrocardiogram or EKG and LVH. to left ventricular hypertrophy, which is a thickening of the heart, so it is a consequence of high blood pressure and proteins or proteins in the urine are a reading of kidney disease, so it is a consequence of high blood pressure and is They measured a marker of kidney disease in the plus points. Does anyone know who this individual is? Yes, I'm sorry, no, it's not Dick Cheney, he's had a lot of heart disease, but I'm sorry, it's not me, no, thank you, luckily it's not me and none of you, it's not Bill Clinton, this is an individual who passed away. this is Franklin Delano Roosevelt this is his blood pressure and the arrows were referring to various events around 1945 and when I say why we care it's because people didn't care for a long time hypertension has long been known as the silent killer and has afflicted individuals throughout human history, this being one of the most famous examples and dr.

Franklin Roosevelt died of a brain aneurysm and, as noted, there was, quote, no indication of eminent danger even though this blood pressure was astronomically high, with blood pressures reaching 200 millimeters of mercury, which would send anyone to the emergency room. these days and you already have demonstrable consequences of high blood pressure long before hypertension care has improved since then and I'd like to go over a little bit about where we are now with that hypertension care so this is another graph or The The grid rather describes the current target blood pressures, so if there is one particular slide to pull from this first part of the talk, it will probably be this slide, so they refer to different stages of hypertension or conditions and the first column is systolic blood pressure. level and the second column is the diastolic blood pressure level, this is what

doctor

s use to categorize or phenotype patients who come to see them, so we start with what is considered normal blood pressure, which is less than 120 over 80, the second category is prehypertension type, this is a category that is really difficult to name because it comes with a lot of baggage when you name a condition like this, but it is considered to be between a hundred and twenty to about a hundred and thirty above something less than 80, so a blood pressure of 125 over 75 would fit into that category.

The next step is hypertension, which starts with stage 1 hypertension when the blood pressure, the top number, the systolic blood pressure is between 130 and 139 and the bottom diastolic blood pressure is 80 to 89. and this is a table and/or, so if you have a blood pressure of 125 over 85, you would fit into this category because even though your top number is less than 130, your bottom number is greater than 80 millimeters of mercury and the last category is Stage Hypertension 2, which is when the blood pressure is greater than 140 for systolic or diastolic is greater than 90, so these are the newest recommendations based on several different societies, they are not agreed upon or followed uniformly, but They're a. of the most popular national guidelines and that is why I chose to show them to you here.

Oh, I forgot to describe my symbols. I just realized that the cuff at the bottom right is that symbol is a sphygmomanometer which is something that is attached to all the blood in the poem. The pressure monitors you all have are a cuff on your bladder and we'll go over it a little bit, but I hope it's fading. I hope the use of these things is fading over time and I will explain. I'll explain it. why and I hope that the use of a SmartWatch comes into play in the near future. Yes, so the question is whether systolic blood pressure or diastolic blood pressure is more important.

The simplest answer I can give you is: Both are important. I tend personally and every

doctor

is different. I tend to go by systolic blood pressure more particularly as a simple way to track things, but also because it's more common for the two to track together. In cases on the periphery of normal where the two are completely unrelated, then it is a slightly more difficult problem to manage, but in general I follow systolic blood pressure a little more than diastolic blood pressure, but in reality one follows both and it looks like both, if that helps clarify what this slide is, this is a history slide, so this is a slide of the target blood pressure level above which is considered hypertension for different guideline recommendations along over time, so on the y-axis is blood pressure in millimeters. of mercury in blue is the systolic blood pressure target and in orange is the diastolic blood pressure target and on the in the United States and the points along the path represent different trials on the x-axis and the points in the middle of the graph represent different guideline recommendations over time.

You can see here that the lines are moving, we don't have the same blood pressure goal. that we did in the time of FDR or Kennedy or Lyndon Johnson, we now have a lower blood pressure goal and that blood pressure recently dropped in 2017, so the table that I showed on the previous slide of our level of what is considered controlled blood pressure that table has changed just in the last two years, so 130 over 80 will be the number that I want everyone to remember at the end of this hour, it's the next slide, so how do we measure this blood pressure? because it is important and it is important for the long-term sequelae of hypertension, so what is shown here is a slide that I have intentionally not made readable.

This is a slide taken from the guidelines. This is a chart from the American Heart Association. and the American College of Cardiology as well as several other societies that met and published guideline recommendations in November 2017 and this table represents all the things that

need

to happen to prepare a patient to measure blood pressure, so these things They are related to sitting, being calm, avoiding certain medications and/or habits, coffee, cigarettes, etc. before measuring blood pressure and repeating that blood pressure and arriving at a number because this number as we covered it is very important and so arriving at this number the measurement should be as accurate as possible.

I can probably count on one hand how many of you probably went through blood pressure this way instead of probably how you got to the Hoover Pavilion today or how you would normally get to a doctor's office, which is you have to park, run in and be approached by someone at the reception and then they probably took your blood pressure not in a quiet room but in the hallway, probably simultaneously when the thermometer was in your mouth and they were reading your pulse and he asked about your medications and saw people going by hehallway, it's not like that, it's not normally done the way this table represents, but I think we have to have a standard and this table represents what that standard is, so it's important to know that blood pressure is not measured so accurately in the vast majority of cases in typical routine clinical practice, which in some respects is a farce.

This is an important number. It is a vital sign, and yet it is not measured at all with that precision. did at Stanford and this article was published about two or three days ago by one of Stanford's medical students and colleagues of mine and it represents a way of measuring blood pressure that has been introduced in recent years to possibly level the playing field. game, since In this graph there is a comparison of two measurements and one of them is routine clinical blood pressure, as I illustrated above, and the other is something called O BP, which stands for Automated Acela Metric Blood Pressure and is not the abbreviation.

It's not that important, but the concept is probably more important: the concept is that you sit in a quiet room, a professional puts a handcuff on you and then you press a button on the machine and that counts down for about five minutes, so the blood pressure is not taken for five minutes, then the blood pressure is taken about a minute apart three times and then averaged so that a machine is not required, but that is not the usual way it is measured blood pressure in clinical practice, but when blood pressure is measured in this way, it is important because in many clinical studies that are used to inform clinical guidelines, blood pressure is measured in this standardized way, so we are really comparing, we're really comparing apples and oranges when you have a blood pressure in the clinic if that blood pressure is used to dictate your care versus what is done in a clinical trial that was used to determine what the goals of blood pressure, so on this graph on the x-axis is an average of routine clinical blood pressure and blood pressure taken sitting and resting or AOB performed by an OBP and on the y-axis is the Delta between those two measurements, so which is about two hundred and two hundred and fifty measurements on various patients here at Stanford over about a year in our hypertension specialty practice and the first thing you'll notice is that at any blood pressure level, the first patients come in with very different blood pressure levels, there are some patients who come to the clinic with a systolic blood pressure. blood pressure of approximately 130 and there are other patients who come to the clinic with a systolic blood pressure of up to 180 or 190 millimeters of mercury.

The second thing that's okay, the second thing you'll notice is that at any blood pressure level, the difference between a standardized automated blood pressure is very different and can be very different from routine clinical blood pressure, so in average and the midline indicates the average, routine clinical blood pressure is approximately 10 millimeters of mercury higher than automated blood pressure, wait five minutes. systolic blood pressure, which means that if your blood pressure was 125 according to a routine clinical measurement, on average in this study the blood pressure obtained with an automated cuff after five minutes was about 115 millimeters of mercury, but that is a average for 200 to 250 patients.

For each individual patient, and in this graph a doctor is referring to an individual patient, the number could vary widely, so you could have a blood pressure that was 20 to 30 points higher if you rested or was exactly the same as if you rested or not. . or it was 40 or 50 points lower if you rest, so it's not really possible to take all of your routine clinical practice and just subtract 10. You actually have to measure blood pressure in a routine, standardized, automated way to generate that pressure. snatched artery. quote unquote, the playing field and in this particular study, when we looked at patients who were over 130 years old and over 80 years old, in other words, they were not at the target blood pressure according to the national guidelines, around the 25 percent of those people, so one in four If you would have a lower blood pressure than the target if you used a stopped blood pressure or an AO BP blood pressure, in other words, if we were to rely on routine clinical blood pressure, we would be overtreating approximately one in four patients, which would overtreat blood pressure. it also leads, it also has consequences, patients will fall, patients will have side effects from medications, these things matter too, so the consequences of higher blood pressure matter and the consequences of lower blood pressure matter too , so one of the guideline recommendations is to measure blood pressure after five minutes of rest along with some other parameters, but that's probably the most important factor to be honest and that's important for clinical care and if you look at in some of those long-term sequelae that we mentioned earlier, like heart attack, stroke, heart. kidney failure, kidney disease, they track much better with a resting blood pressure or BP measurement than with routine clinical blood pressure because this graph illustrates that routine clinical blood pressure is not as accurate, there is a lot, that's a lot.

That comes into play, whether someone is walking down the hall, whether you're talking at the same time, whether you're late, whether you're running to practice or maybe not, maybe you're completely calm and your routine is clinical but press. exactly what your blood pressure would be at rest, so this really helps level the playing field and is something that the national guidelines recommend, daily activities, this increases stress, etc., compared to your relaxed measures, so that for the audience at home the question is how to do it? Consider out-of-office activities related to blood pressure and I'll address that in the second part of the talk because the reality is that it's not currently taken into account as systematically as we would like, but it is important for the outcomes that matter. . for the long-term after-effects of high blood pressure, so I'll talk about that in the second part of the talk, if you don't mind.

I think I want to save the rest of the questions for then, thank you, since hypertension is a condition, which is a term that I pause before saying because high blood pressure is thought of in many ways. I call it a condition, some people call it a disease, some people call it an indication, but it's not always thought of the same way and it's seen by many different professionals, so I'm a kidney doctor and I see people with high blood pressure. , but you will find primary care doctors family medicine doctors obstetricians obstetricians cardiologists nephrologists endocrinologists neurologists there are such a variety of specialties that have some domain that affects or is affected by high blood pressure, so many different doctors deal with the high blood pressure and everyone approaches it differently depending on what specialty they are from, that's just a fact and what I would like to do now is just approach it from the idea that this is a disease in itself and if It is a disease in itself, it has a cause and it has risk factors for how you would do it.

Get it and those things are important because controlling this disease, as we mentioned earlier, can prevent the long-term sequelae of high blood pressure, so the pie chart shown here refers to the general population of hypertension patients in terms of cause, so there are a small number of patients. who have what we call secondary hypertension and that term comes because most patients have primary hypertension and primary hypertension also has other names probably that are much more familiar to you, one is essential hypertension, which I think is a horrible name because it doesn't There is nothing essential about having high blood pressure or idiopathic blood pressure, which is probably a more accurate term because we don't really know the cause of everyone having high blood pressure and we can guess pretty well, but we don't actually do as many tests to determine what is the cause of high blood pressure because it is very common and most of the time we can't identify it so we don't spend a lot of time doing tests and trying to find out the cause which is surprising if you think about it.

There aren't many specialties, conditions or diseases in medical practice where you don't bother to find out why you have it, and it affects 1/3 of the US population and half of all people over 65 years, and we just attribute it. to just general bad luck and it's common, so part of trying to figure out what the causes are is something that I think will occupy the minds of hypertension specialists as we move forward, but at the moment, 95% don't have it . an identifiable cause and have what we would call idiopathic or essential primary hypertension and approximately 5% will have a secondary or identifiable cause of hypertension, so although we do not know the cause of patients with hypertension, we do have an idea of ​​what add gasoline to the fire?

So what are the things that can exacerbate high blood pressure that can potentially be taken by someone who has it and

need

s one, two, or three medications? By eliminating these exacerbating factors, you can reduce them in terms of the number of medications you take. need or in some cases can take them below the target level to the point that they don't need medication or to the point that their blood pressure is normal, so this is partly the cause, but mainly we think they are factors exacerbating factors and these are the most common, so the question relates to sodium and I have dietary sodium listed here as an exacerbating factor.

Let me address it when I get to that in a moment, so one of the most common causes of high blood pressure is obesity and when I say common I mean that about 70 to 80 percent of patients with obesity have hypertension. It's surprisingly common. Equally important with respect to that risk factor is weight loss. Obesity helps reduce blood pressure. Therefore, this is a big problem. part of what we call the diet and lifestyle measures that we use and that we talk about with patients with hypertension or even patients with prehypertension who do not have normal blood pressure but do not yet have stage 1 hypertension, a second is the lack of exercise or a sedentary lifestyle and this is also true, the other side of the coin is true, in other words, if this is identified as a factor for high blood pressure, increase exercise or decrease a sedentary lifestyle will help lower blood pressure, the third of these is something that is not discussed very often, but is very common in patients with severe hypertension, which is obstructive sleep apnea.

Can I have a show of hands for those in the audience who have heard of obstructive sleep apnea? or sleep apnea or OSA cool that's what makes me I'm happy I'm happy because it's so important that that message gets out to those of you who haven't heard of this obstructive sleep apnea refers to the idea that you stop breathing due to an obstruction in the airways and this is the responsibility of both pulmonologists and sleep medicine doctors, who can perform tests to detect this and treat it. I should say that also ear, nose and throat doctors can treat this as well and the worse your blood pressure is, the more This helps to be identified and treated, so without getting into this too much, one of the things we try to do in a specialized hypertension practice is to ask about this consultation and perform tests if we suspect it, because it can really make a difference. to lower your blood pressure more if you have severe high blood pressure than if you have a blood pressure of 131 over 81 where it's just over the line, it matters a lot more if your blood pressure is much higher in the next point This is the diet that is probably the one that we, as hypertension doctors, are asked about the most, because it is one that people can most easily influence in their daily lives and I have written here the high sodium diet and when I say high sodium diet there are many ways. define that, according to the recommended daily allowance in the United States, you want to have less than two grams of sodium in your diet and this refers to sodium, not sodium chloride or table salt, so sometimes it can It might be hard to convert the numbers, but by the way the nutrition label on any food purchased is written in milligrams of sodium, so if those numbers add up to less than 2000 or less than 2300 that I've written here, that would be considered a standard for a diet. low insodium, average sodium.

The diet is probably double or almost triple that of the average American, so it's an important part of how this is asked in clinical practice and it varies widely. This may be something you can talk to a dietician about. This may be something that doctors will do. Ask if he adds salt to his food or if he has table salt to add to his food. You are sometimes asked how often you go out to eat because, in my experience, that is a good indicator of how often you get sodium because foods eaten out are usually flavored with a lot of sodium.

Another way we've tried measuring sodium is if we don't feel like we have a reliable track record or if something doesn't fit the picture quite clearly. This will do a standardized steady state urine collection to quantify the amount of sodium over 24 hours and while this is not completely accurate all the time and probably the more data the better, it gives us a slightly better window on the amount of sodium. In diet there are a variety of studies that say that a diet high in sodium can lead to worsening blood pressure. There are a variety of studies that say that a high sodium diet can lead to poor hypertension outcomes, so the long-term sequelae of hypertension, such as heart and kidney disease, there are other studies that will actually say that sodium does not matter for long-term outcomes, as the gentleman mentioned here, it's a highly debated topic, but some of the data I think he's referring to is completely I'm sure about the study, but I think the one he's referring to takes into account a number of patients who do not yet have high blood pressure, so not all are patients with incident high blood pressure in most studies that talk about patients who already have high blood pressure, reducing sodium in the diet can help Substantially, you are not immune to the same rule that applies to everything on this list, which is that it varies from person to person, so if you are obese and have high blood pressure in a patient or For an individual, a loss of 10 kilograms will have a profound effect on blood pressure, while for another individual it might have only a small effect.

The same goes for exercise. The same goes for obstructive sleep apnea. The same goes for reducing sodium in your diet, so each person varies. and the factors that cause people to vary are partly environmental and partly genetic, but it's important to know that most of the studies, these things have met the standards of the practice guidelines and have stood the test of the time, especially in patients who already have high blood pressure when you're talking about people who don't already have high blood pressure and you're looking at whether these measures will prevent bad things related to hypertension, like heart attacks, strokes and kidney failure, it's not so sure, but in patients who already have high blood pressure the data is quite clear.

The last comment I have here is about medications, so it refers to both benign and not so benign forms of medications, probably the one I've listed here that I find most useful to refer to in clinical practice is pain relievers, so nonsteroidal anti-inflammatories or NSAIDs, which include things like motrin ibuprofen Aleve Naprosyn naproxen these are medications that when taken chronically not just for a week if you have an orthopedic injury, but when taken routinely and chronically can exacerbate the high blood pressure and we look for them for a variety of reasons, but we look for them in the kidney clinic and the hypertension clinic, the other things on those lists can often influence blood pressure in the here and now, so Things like tobacco can increase blood pressure, illicit drugs like cocaine and amphetamines can acutely increase blood pressure.

Nasal decongestants like Sudafed can raise blood pressure acutely, so we ask about these things, especially if someone has very high blood pressure in the clinic and you're assessing whether that's part of their routine blood pressure that they have. at home and in the clinic, or is it just that at that particular time, yes sir, then the question is why would we prescribe aspirin to lower blood pressure if aspirin is on this list of pain relievers and the answer is that aspirin is an exception to that rule. aspirin is an exception. As a rule, it has some of the side effects of nonsteroidal anti-inflammatory drugs, but it does not appreciably increase blood pressure, and it has so many other benefits of saline that it is something we often recommend, but it is not specifically recommended to reduce it.

However, blood pressure, but at least according to recommended practice, is given to many patients who also have hypertension because it is given for conditions that are commonly associated with hypertension or caused by hypertension, such as a heart attack, heart failure and other cardiac abnormalities. so peripheral arterial disease, carotid disease, that's why patients who take aspirin and have hypertension can often associate the two, but it's not usually given for hypertension specifically for deception, so tylenol is an exception to this rule. Narcotic medications are also an exception to this rule if you don't mind, we can ask more questions at home at the end, but this is great.

I'm glad you have a lot of questions, so this slide is another pie chart of a breakdown of Do Pathak's Primary Exceptional Hypertension. versus secondary hypertension and on the first slide we had a ratio of 95%, 95% to 5% and here I am showing a much larger slice of the pie associated with secondary hypertension, so this pie chart refers to those patients who have severe hypertension. and I haven't given you the definition of severe hypertension yet, but it generally refers to patients who take their medications and take multiple medications, up to three or four medications or more, different classes of antihypertensive medications, and despite that, they still have blood elevated. blood pressure, they try to address the risk factors that we discussed on the previous slide and despite having high blood pressure, they are compliant with our medication and despite that, they have high blood pressure, so in this group this represents approximately a fifth of all. patients with high blood pressure, that means that 80% of patients with high blood pressure do not have severe hypertension, but 20% of them do, and if one third of the country's population or one hundred million people have high blood pressure high blood pressure, 20% of a hundred million is a large number, so this is commonly found in clinical practice and because of the notion that they are five times more likely to have a demonstrable cause of their high blood pressure, this is the population that could get special screening tests for high blood pressure why do they have high blood pressure?

Let's see if there is a specific cause that we can address and treat instead of giving a general therapy that would apply to anyone with essential hybrid, that's why I put this graph, this doesn't apply to everyone, if you walked into a clinic with a blood pressure 135 over 85 and you were 59 years old, they probably wouldn't do a ton of tests, ultrasounds, MRIs and things like that, but if you have severe hypertension and you've bounced around from doctor to doctor to doctor and nothing is controlling your blood pressure and you've been through years, you may encounter a doctor who sends you a series of different tests looking for different secondary causes of high blood pressure.

I don't want to get into this because in the entire hypertensive population it is still only about 5%, but there are many different causes that fall under this umbrella, so if you have high blood pressure and are being tested to determine the cause of that high blood pressure your doctor is probably looking for the things on this list some of these things are much more common than others some of them are extremely rare and I don't have time to go into all of these things, but there are things that we do know that cause the blood pressure that we can identify as a specific cause or treat as a specific cause, so in certain patients we will look for them; those certain patients include patients with severe high blood pressure, they also include patients who are 25 and I have high blood pressure, very young and yet I still have high blood pressure because that is not a common age to develop high blood pressure or 85 because it is not a common age to develop high blood pressure suddenly so there are different cases where we could look for causes of high blood pressure and there are many more cases where we could go ahead and start treatment from the beginning so just to give you that distinction of what we now know is part of clinical practice, oh, we're running out. of time, so I'm going to go a little faster through this because it's about data and it's probably more important to get to the end result of this data, so this is an image of the article title from an article that came out in 2015 about four years ago in the New England Journal of Medicine, which is a preeminent medical journal and it's titled a randomized trial of intensive versus standard blood pressure control and this reported the results of a study called the Sprint study, which was a acronym that referred to a systolic blood pressure intervention trial.

I'm going a little deeper into this particular study because it heavily influenced the current guidelines that were revised in 2017, so this was a study that involved over 9,000 people and the study was designed to ask one particular question at the time. The way this study was designed was that the target blood pressure was less than 140 millimeters of mercury for systolic blood pressure, and it had been known for a long time that we might need a better test to see how low we should go. maybe the overall pressure should be as low as 120 millimeters of mercury, so in this trial they enrolled patients and flipped a coin and the patients were in the group that used enough medication to get down to a blood pressure of 120 or less and the other group went down to 140 as was the convention at the time and followed them and saw if they developed the long-term sequelae of high blood pressure in the form of death from heart attack and stroke and this trial was particularly important because it involved and was enriched for cohorts.

Of the people who don't get in, they don't enroll in all blood pressure trials and have been involved in smaller trials before that, but this was going to be the largest enrollment of it in several different subgroups of patients, including the elderly, including patients with prior cardiovascular disease, patients who already had high blood pressure sequelae or high risk of having high blood pressure events and also patients with chronic kidney disease and the punchline is that the trial ended early in a big New York Times article . made the lay press the safety monitoring board realize that patients who had a blood pressure below one hundred and twenty were having so many fewer events than patients whose goal was just under 140 that it was not ethically possible to continue the trial in which I had to stop and report the findings, so about a quarter there was about a 25% reduction in the risk of having a heart attack or stroke or death in the group that was less than 120 versus 140 and there were more events associated with low blood pressure in the group that went down to 120, as you can imagine, but overall mortality was improved if you had a lower blood pressure than if you had the highest convention at the target time and when They tried to see if there was a cohort. of the patients that really drove this result by strongly influencing the average, there was not this referred across the board to different subgroups and every time the average fell on the lower side it is better and that is why these charts are on the lower side left of that vertical bar greatly influenced the American Heart Association's American College of Cardiology guidelines and these guidelines were put together by a team of experts that included people here at Stanford and they asked a number of questions, they asked what our goal of blood pressure, how low it should be.

Come on, they asked what antihypertensive medications should be used in particular populations and what pattern of antihypertensive medications should be used if we start with one medication and then increase the dose until we reach the maximum dose and only then and only then. add the medication or should we start with a low dose of one type of medication and then add a low dose of a second type of medication if patients have no control and then the last question is whether there is evidence for self-directed monitoring. For best results, put another way, if you monitor your blood pressure onhome, does it make it better?

This is really the theme of the second part of the time. Donna, can I ask you a question? If we go a little overboard, I mean, we go a little overboard. Okay, would everyone be okay if we turned out a little okay? I apologize for those of you who have to get back into the game, but I can assure you that it is affecting me too, so this is a flowchart that was part of those guidelines and so on. This is not a straight line, so there are factors that matter when you're trying to when your doctor, your advanced practice provider, or your care provider is trying to determine what blood pressure you should have and what the appropriate goal is and how to get there. and so this all sums up in that graph I showed earlier: if your blood pressure is less than 120 over 80, that's normal and there's nothing to do if your blood pressure is over 140 over 90 or stage 2 hypertension, that It is easy. start taking the medication, the problem gets in the way, what do you do if you are between those areas?

So if you're between 120 and 130 on the higher side of the number, we consider that to be prehypertension and it's not quite normal, but it's less than 130 and that. is the realm under which we provide a lot of guidance on diet and lifestyle measures, things like controlling weight, increasing exercise, reducing sodium in the diet, asking about risk factors, I mean, that's the realm in which So those things will still make a difference if your blood pressure is over 130 or even over 140 or 150, we still use those measures, but it's when the blood pressure is higher that we have to use medications from the beginning depending on what as high as your blood pressure is, so the biggest and most complicated part of this table or this flowchart and the most controversial part came when you had a maximum number that was between 130 and 139, so this is if you remember the goal before the sprint before that systolic intervention. trial that is being published, the goal was to get a pressure below 140 and here we are, your blood pressure is 135, what do you do?

Is it based on that Sprint essay that just came out that was picked up early in the New York Times? follow the tried and true convention from before that said you are under 140 nothing to see here nothing to do here go on with your day and the answer that the guidelines committee and the writing committee decided on was that it was nice it depends on the risk you have, so if it is between 130 and 140, then an ISO cardiovascular disease risk score is used to determine your risk of suffering from the consequences of high blood pressure, such as heart attacks and strokes, etc. .

The ones that come into that equation involve age, they involve other factors like cholesterol and your doctor can calculate a risk score in about three seconds using an app using Epic, you're accessing the internet, everyone can do it, it's very simple. But if that score exceeded a certain value, then it was considered prudent to start taking medication, and if there was no risk and your blood pressure was above one hundred and thirty, then it was considered safe to employ the standard diet and lifestyle. The changes don't need medication yet, so it's a complicated system, but generally our goal is to get your blood pressure below 130 over 80.

How you do this depends on your risk, whether you can use dietary and lifestyle measures. lifestyle or whether you also have to use medications in some patients, it is quite simple, in other patients it is a little more controversial, so the summary of the guidelines was that and this was in contrast to the previous guidelines in Prior in previous generations, which was that there was a different number for different groups of patients, if you were 85 years old, you had a number if you had chronic kidney disease and diabetes. had a different number and it made it very confusing, so one of the goals of the writing committee was to try to make this as simple as possible and back up what they said with as much data as possible so that, for the general population, the goal was less than 130 more than 80 I still considered the guideline recommendation which was the same if you were under 60 or over 60 which was the same if you had kidney disease or you did not have kidney disease which was the same if you had diabetes or didn't have diabetes, that last point is a little controversial because this study didn't include diabetics on purpose, but based on other studies that I didn't have time to get into and based on other analyzes since sprinting was suspended, this pattern was felt.

To be appropriate also for patients with diabetes, this is a quote that applies to the guidelines but was not part of the guidelines, which is that the use of any medication that lowers blood pressure to help protect patients from accidents strokes or other serious events is more likely to help than not giving patients any medication, so I think this is a generally true statement. Certainly, if your blood pressure is 115 over 75, you don't need any medication, but I try to follow the saying that the higher your blood pressure, the more benefit you will get from medication and the less likely it will cause you harm, so that the type of medication to use is probably less important than the use of medications and that all groups are likely to benefit from some blood pressure control.

Some groups may benefit from one particular type of medication more than another, but they benefit from some medication or no medication, so although I don't have time in this hour to go over the specifics. types of antihypertensive medications we had free time for that in question period, but some medications are better than none, so for part two I wanted to discuss the future and what we know now and I changed my symbol to a SmartWatch to reflect This I mentioned earlier when we talked about high blood pressure and one of the questions from the gentleman on the left was what about all the things that happen at home and what is the blood pressure like at home and the title of the slide? is outside the office, blood pressure is more strongly associated with risk than routine blood pressure in the clinic and that's true, so what's shown in this graph and as I complete it is the y axis is the risk cardiovascular at two years and on the x axis The axis is systolic blood pressure and this is a kind of risk for routine in the clinic.

Blood pressure was taken from a 1999 study, but now applies just as well compared to daytime blood pressure which is measured by a monitor that is placed on all of you. day or measured, you know it routinely and periodically throughout the day versus the 24-hour average blood pressure which also incorporates the nighttime blood pressure, but look at this last one, this last dotted line is the nighttime blood pressure, so this tells me that nighttime blood pressure Blood pressure, the blood pressure that we don't measure as often now is the one that matters the most for cardiovascular risk, so in terms of home and office, there's actually four categories of hypertension that one could have, so I have two: two by two table that we are going to fill with boxes here and on the x axis there will be two fields of normal blood pressure at home or high blood pressure at home and on the y axis There are two camps of either normal and clinical blood pressure or high and clinical blood pressure, so the first box is probably the most self-explanatory: It's normo blood pressure or normal blood pressure when you're clinically normal and normal. at home you're normal all the time nothing to do and the last box on the bottom right is also probably the simplest of two to think about: sustained hypertension, so this is high blood pressure in the clinic and high at home and when I say high at home I mean during the day at night. one or both boxes at bottom left high blood pressure and clinic blood pressure and normal home blood pressure this is often known as white coat hypertension because patients may respond with stress or some other identified factor and have high blood pressure at the clinic, but you know, doctor, when I'm at home, my blood pressure is totally fine, that blood pressure that you have is not accurate.

I'm fine at home, what do I do? So that's that chart and the last chart here is probably the least intuitive one is that the blood pressure is normal in the clinic and yet the blood pressure readings at home are quite high and this is known as masked hypertension, so the term was first coined by dr. Pickering in 2002, but currently it receives about a sentence and a half in the national guidelines, but if you measure the percentage of patients who have each of these, it is a little less than 10% of all patients who will have Hypertension masked 8.4 percent, so this data was taken from approximately 63,000 patients in Spain who had their blood pressure taken in a clinic and also had a 24-hour ambulatory blood pressure monitor placed on the top of the arm to get readings during the day and at night and generally at home, what's shown here is the all-cause mortality when you look at the different groups here and masked hypertension had a higher risk of mortality than sustained hypertension , which means if you're high at the clinic and high at home, you'd be better off than if you were high at the clinic and high at home, which is amazing and it's the most underdiagnosed because unless you measure your blood pressure at home, You would never know that you would never unmask that you have masked hypertension, so this is common and has consequences. and currently it is not diagnosed as much, so I put it in this part of the talk because it is what we need to know in the future, so how are we going to evaluate masked hypertension?

So I have some photos later, but I think. One of the ways this will become a reality is with wearable technology and things like a smart watch that can measure many things and things that are attached to the patient or the individual is a huge industry that is predicted to be a hundred. billion dollar industry by 2024 and probably a hundred and fifty billion by 2027, so whether you have a smart shirt or a smart watch or anywhere in between, they are all considered wearables and for wearables for the healthcare, there are actually three categories that they fit into, these are things that are part of just collecting information for the sake of collecting information, the term that is used for this is called infotainment, so entertainment based in information will also be useful in the future for things like precision medicine, which is a term our medical school dean uses a lot.

Here when we talk about the future of healthcare and also precision trials where we can track data much more accurately to measure outcomes and currently there are many things that we can measure with current devices, we can measure dietary intake by either taking an image of a piece of food or a package a coded number of the package Oh, or by simply typing a calorie count, we can measure body weight using a scale that can automatically send via Bluetooth the weight to your phone and then to your doctor we can measure other vital elements. signals that can measure temperature, heart rate and rhythm Apple, the Apple Watch, the version for which just came out this year, can actually measure an equivalent of an electrocardiogram and can detect atrial fibrillation as approved by the FDA , which means there is a lot more data. going to doctors and researchers now more than ever, we can even measure respiratory rate and even sleep properties through a smartwatch, we can measure activity with certainty and anyone here who has a Fitbit or Apple watch or anything in between can measure activity. get genetic data that can be incorporated into the evaluation of the other terms here and in the future, hopefully, we will have wearable blood pressure, why does this matter?

So why would we care? We would care about the reason I showed. in the previous slide, that blood pressure at home is important, blood pressure at night is important, and yet even if we measure blood pressure at home on a piece of paper and write it down once or twice a day, that's a burden for the patient, it is not uniform. fact on all individuals some people rest before measuring their blood pressure some people don't take it in the morning some people take it at night some people think both some people take it at 12 o'clock some people take it two or two three times and then average it some people do it for a week and then don't do it at all it's completely arbitrary the data we get and we don't have standardized blood pressure at home there is a way to measure it like in the Spanish study where you can use a cuff for 24 hours, but that certainly won't be something that most peoplePeople use it all day, every day for a month and one of the questions that has arisen is how often should we do this, let's say.

You had a device that could measure your blood pressure, let's say it was a watch that couldn't measure your blood pressure or a wrist device of some kind. What does matter according to a couple of different studies is that increased frequency of blood pressure monitoring does. alter both the precision and the accuracy and that's important because the more precise data intuitively is not necessarily that important, but the more precise data is definitely important and it's because currently the way we care for hypertension as we go forward for the goals and if the blood pressure device one has is more accurate by getting more measurements, then one is likely not to over or under treat for the same reason as if using stop blood pressure with an AO BP device, it is less likely to be inaccurate in terms of blood pressure. that's important compared to routine clinical blood pressure, so how would we do this?

The chart on the left is probably the most common way most people do it. They have a blood pressure cuff at home, and I suspect many people in the audience said yes. most of you have a bracelet on your upper arm instead of a bracelet on your wrist and you write down the blood pressure or use Bluetooth on your phone or write it on an iPhone or keep a log, but it's usually different from a patient to another, some people bring in Excel spreadsheets with calculated averages and nice smooth graphs for months, not everyone does that and it's not completely clear if it's more useful, but other people will do a 24 hour ambulatory blood pressure where their doctor or care provider gets a report like the one shown.

On the right we have a reading for the 24 hours and we know what percentage of the time it is above the target and what percentage of the time it is below the target and depending on the intelligence of the bracelet and the participation of the user. actually has information about what one was doing at the time the blood pressure was measured, for example, exercising, walking, etc., and this can measure blood pressure during the day, blood pressure at night, etc., so the device on the right is probably the standard of care for measuring nocturnal blood pressure today, but how did we get here?

The first recorded measurement of blood pressure actually occurred in the 18th century in a book called Hemostatics, and a manometer developed shortly after. the gentleman who invented Poe's cell law and then invented the sphygmomanometer in 1881, the one you all have now is not that different from the one back then, we need a change in 1905 dr. korotkov coined the term for Korat cough sounds, which is important because that is what your healthcare provider uses to measure your blood pressure if you use a wearable device and listen with a stethoscope to get your systolic blood pressure and diastolic blood pressure.

Then in the 1990s, Scilla metric devices for the home and office became much more common. These are probably the type you have at home if you don't have a mercury manometer or aneroid cuff and have often replaced a mercury cuff. for standard practice and they're pretty accurate, but what the new wave looks like if we look at how we would measure blood pressure frequently and throughout the day and night, you know we need This idea of ​​masked hypertension has been around for about 17 years in 2015, which was kind of the year of hypertension if you think about it, this is the year the Sprint trial was published, this is also the year the US government issued a recommendation. that if you have high blood pressure at the clinic, they were going to reimburse you for doing a 24-hour ambulatory blood pressure at home to formally diagnose hypertension and not give it to a patient who already has hypertension to make sure their blood pressure at home it's accurate and it doesn't have masked hypertension, it was just used to look at white coat hypertension and that's an important distinction then in 2017 these guidelines that I was referring to came out and the idea of ​​using an ambulatory blood pressure came up.

The monitor wasn't fully recommended for patients with existing hypertension, but there was expert opinion that it's a good idea in cases where you're not sure, and then last year the Centers for Medicare and Medicaid Services called for to the medical community to comment on the idea of ​​using an ambulatory blood pressure monitor more frequently maybe we should reimburse for this maybe this is important maybe measure blood pressure at home and diagnose with a maskhypertension should matter so I'm proud to say that the Center for Medicare Medicaid Services heard many hypertension experts from around the country comment on this and provided data, references or expert opinions that it should be considered more frequently and that there are some current changes that have been proposed proposals that I think are still in the works, but it looks like very soon an ambulatory blood pressure monitor will be available more likely than in the past, so we'll have to see what happens next year.

This is a slide. of new blood pressure devices that are not on the market yet and I put this in just to give you an idea that there are companies that are working on this, there are different types of blood pressure devices that can be a blood pressure cuff. the finger or on the wrist or even a blood pressure without a cuff using a different way of measuring pressure and pulse wave velocity than blood pressure or using the back of an iPhone like Samsung has on the back back of your iPhone. one way to measure blood pressure or use other techniques and each of them has its advantages and disadvantages and some of them have been endorsed by the FDA but there are, there are different ways to measure blood pressure.

I have shown an image here. Somehow, some of them there is something called heart guide ha emraan, which is actually an FDA approved watch. I'll stop and say that I don't work for Omron at all and haven't seen their validation. data, but this watch is available for public purchase. I wouldn't warn everyone to go out and buy one nor do I think consumers are going to buy one that often, but the idea of ​​there being a watch that has a bracelet like a bracelet that can measure blood pressure and is supposed to be accurate It is an advance compared to the 1881 technique that we have been using all this time.

There are other blood pressure devices, the one on the top right is the only one that is actually not a blood pressure cuff endorsed by the European Society of Hypertension, which is one of the validation bodies. None of you would probably be caught wearing this device for more than a few minutes, but it is one way to measure blood pressure. no cuff but you have to be at rest which is a plus for night time blood pressure not a plus for going to Trader Joe's and the data on the bottom right is just a different technique that comes from the company I helped .

I don't want to say anything more about that right now. I think with all of these new devices it's very important to be careful and probably within five years there will be many more ways to measure blood pressure than there are now and they will all be validated and supported and will be familiar to your healthcare provider, but in this moment I wouldn't say that's the case and validation is absolutely critical. What is shown here is a cardiovascular medicine study here at Stanford. which looked at a variety of different wearable devices that looked at heart rate and energy expenditure, how many calories you're burning or what your heart rate is, and these are things like Fitbit Apple watches and other different types of devices and they took about 65 patients. and they had them run on the treadmill, they had them raise and lower their heart rate, they measured energy expenditure in two different scenarios and then they used the gold standard to compare and for heart rate devices it was pretty good, the error rate shown here by The yellow bars on the left indicate that you know a device is off compared to the gold standard and on the right it is vice versa, but look at the power expenditure, the error bars are huge, this smacks of inaccuracy and to the need for validation and the same. it's true for blood pressure in 2017, there was an app called I think it's called instant blood pressure.

There was a company that now no longer exists, but they advertised that their blood pressure device accurately measured blood pressure and was a device that now seems voodoo, which was that they were instructed to hold the device up to the breastbone and wait a few minutes after pressing a button on a machine and then the blood pressure appeared on that device and colleagues at Johns Hopkins decided to validate that device and found that it was inaccurate about 80% of the time, but I had already passed, I hadn't had thousands and thousands of downloads at the time and it took an article in a major publication to bring that device down. but not before I was sure that some patients bought the app and God forbid they used it to influence their care, but it was 80 percent inaccurate, so validation is critical for all these new devices, so I'll leave them with the idea. that multiple modalities are being developed, there are ongoing problems with all of them, the artifact of rest versus movement is large, shape matters, we know patients won't use something all the time if it's clunky, right? and how often a patient actually needs to interact with the device rather than something that just passively measures their blood pressure is very important, there are many examples of apps that can input all kinds of data to your device and then transmit it to your healthcare provider. healthcare, but if you have to write constantly all day, it is unlikely that you will continue to do so in the long term, so patient participation is important and I cannot emphasize enough the importance of validation and it will improve synergy between patients and suppliers as long as it is accurate, so I would.

I would like to finish, there was some of what we know now and what we should know in the future and answer any questions. Thank you for this. I guess I'm going to start with the gentleman in the back, so the question is, do beta blockers reduce adrenaline? And how do they reduce adrenaline? The answer is that they don't actually reduce adrenaline, but they reduce the effect of adrenaline, so beta blockers and, depending on the type, they can block the receptor that adrenaline or other adrenaline-like hormones act on, and so on. it's like it would reduce the effect of adrenaline rather than the actual level of adrenaline itself during the day it goes up sometimes it goes down yeah how is there any guidance on how often it should be how often can it be baroque?

What happens during the day? I mean, it's very confusing, so the question has to do with what do we do with the blood pressure pattern outside of the office in relation to this number that we're supposed to hang our hat on and the answer is that there are guidelines as to which is the average for the 24 hours that we should follow, what is the average to know what is the average equivalent risk for blood pressure in the clinic of 130 over 80 when you look at it and evaluate it over the 24 hours. versus just the day versus the night, so there are parameters that are equivalent, so they are not exactly 130 over 80, so nighttime blood pressure has to be less than 130 over 80, daytime blood pressure most of time too. to be a little lower than 130 over 80 and in the 24 hours part of the day and part of the night, but there are equivalences and I didn't have time to get into those numbers, but when you do a 24-hour ambulatory blood pressure monitor those equivalents are part of the report and it is reported as such and it is read as such and it should be interpreted as such by a care provider and in the reports that come out of the companies that generate those reports they are meant there.

I would say the most important thing to think about for long term consequences is what your organs see, so what your organs see and average, your organs see an average over time and extremes are things. which are exception. to those rules, so if you have a blood pressure that is less than 130 over 80 all the time, great, it's a simple interpretation, but if you have a blood pressure that sometimes during the day is greater than 140 over 90 but many times times during the day is less than 120 over 80 and the average is less than 130 over 80, you're okay, that would be considered something that would be okay if you have a blood pressure of 80, systolic blood pressure of 80 over 50 a blood pressure that is a hundredeighty over 110 that's not right, so there are acute things, there are acute examples at the extremes that are important for the risk of acute events, so it's a combination of averaging and looking at the data. but in general, the average matters more than the sum of the real numbers, so we don't necessarily query for a number of times greater than 145;

For example, it is probably more accurate to consult the 24-hour average and studies that have assessed risk. Long-term cardiovascular risk is based on the means, not based on the number of times you are less than the target during the day, because you could imagine that if you had all this data and an ambulatory blood pressure monitor captured data on every half hour over a 24 hour period, so that's 48 data points. People who measure blood pressure at home on their own measure it maybe two or three times at most, just when we assess the risk, it's the average over that period of time.

What is used is not the percentage of time greater than 130 over 80, many times those two things will be followed together, but there are exceptions to the rule, so the question is if you are over 80 or younger, are you? you can do it? Your blood pressure is higher and do you have to take as many medications as you did when you were younger? So the answer is that, according to the guidelines of the American Heart Association and the American College of Cardiology, we still aim for a blood pressure of less than 130 over 80. according to the guideline recommendations, but most importantly in care of anyone in medicine for any condition is the individual patient, so part of that is the maximum tolerated medications that people can take, if you have a blood pressure that has been 145 to 95 for decades. because the old guideline recommendations were higher than what you know, let's say 139 over 89, let's just say as an example that was considered normal for years and now we're saying less than 130 over 80 and your body is used to that and then we try give him more medication and bring it down to 122 with a 17 millimeter drop in blood pressure, he'll probably feel that and it's certainly not something we're going to do quickly if we're going to lower his blood pressure. and there are cases where patients just don't feel well and they can have an adverse event by lowering their blood pressure too much, so if we're going to lower both, we make sure we do it slowly and in some cases, if patients don't They tolerate it. that or they can't tolerate any more medications than what they are currently taking, often we won't give them any more medications, but in some cases, if there are no risk factors or no events have happened or there are no effects of the medications that they are adverse and we just had numbers to guide us, we would probably try to slowly lower your blood pressure below that goal.

There are societies other than the American Heart Association that have not agreed with those guidelines that do not recommend lowering blood pressure. blood pressure drops to less than a hundred and thirty above 80 for seniors, but you know the debate will continue and each doctor will adopt their own version of the guidelines and determine how comfortable they are with them, but there will be doctors who will bring that blood . low blood pressure, but there will also be some doctors who don't do it, so it really depends on the individual patient, yes, something for example, a 60 year old, a certain high range of blood pressure versus lower blood pressure, normal blood pressure and with mortality differences.

The question relates to Sistex mortality statistics based on age and high blood pressure, so ages vary, so are there age-specific guidelines? Yeah, yeah, so the question relates to age-specific guidelines for age-specific blood pressure goals, more specifically. More observational studies indicate that for the same given blood pressure, the older a person is, the greater the risk and those curves evaluate blood pressures as low as 115 up to 185, so age is considered a risk factor for most. of cardiovascular diseases. time when age mattered in terms of the blood pressure goal we would achieve so it would affect therapy, the newer guidelines are less, there is less, there is less of that for sure, but the older guidelines had a different limit depending of age and that did It's more if we take our winning group of people in their 60s with 140 over 90 versus a group in the same age range of normal blood pressure.

What is the difference in mortality? So within an age group, how much does blood pressure matter? So the older you are, the more blood pressure control probably matters. I would say yes, sure, but there is observational data that is based on age and blood pressure levels and it is somewhat linear that for any different age group, the blood is higher. Blood pressure will be at higher risk than lower blood pressure, it may vary. You know the extent and magnitude of that risk will also vary with age and generally the older you are, the greater the magnitude, so I can't.

I give you data on the age group of 60 to 70. I wouldn't say it's 50, but it's enough to maintain the same goal. I would say yes, so the question is about pulse pressure, which is a differential between systolic and diastolic blood pressure, and yes. The higher the pulse pressure, this can be a sign of a variety of different conditions, including alpha sclerosis, but also aortic valve disease, a specific type of aortic valve disease, so it can mean different things. and different doctors will give more or less importance to pulse pressure. Can. I'm married to a cardiologist, so I can.

I could say this with confidence: cardiologists look at a lot more pulse pressure than we nephrologists write about, and I just confessed earlier. I look at systolic blood pressure most of the time, but it does matter in certain conditions. Yes, sir, so the question has to do with the structural etiology of high blood pressure, so there are conditions in which diseases in the vessels can affect blood pressure. Unlike standard primary essential idiopathic hypertension, there is something called aortic coarctation or subclavian artery stenosis that will give a different pattern of blood pressure. Those things are less common and there are things that generally present themselves in specific scenarios, sometimes very young. patients or very elderly patients, our elderly patients will present with conditions like the ones we tend to look for, probably not as uniformly and systematically as we should, but these things arise, for example, when the blood pressure and the two arms are different and so routine. different that will give us a clue to a disease in the vessels that are in the upper part of the body, so we look for them in specific cases.

I have had patients tell me doctor, my blood pressure is always lower. on the left there is 15 millimeters of mercury further down on the left, what is happening and there are certain things that we do to separate the artifact from reality and then what tests would you do to go from that point onwards yes, that is correct, there are also physical tests things that affect the arteries that go to the kidneys, which is a form of secondary hypertension that I didn't have time to go into detail about, that can affect blood pressure, there are things that can affect blood pressure the other way around, so what trauma to the baroreceptors in the neck can cause low blood pressure, so there are certainly structural things that affect blood pressure, these things are not as common as garden essential high blood pressure, so we don't look for them nor to all people, but there are clues that we use to know when to look for these types of structural things.

I hope it really becomes important to clinical practice, yes, all the time, the way that institutions take it and maybe they take the lowest number that you have taken, what you are reading says, if they take it more than half an hour. you have so many different readings it's so frustrating I really don't know if my reading is correct and how do you know it's correct tonight? They never mentioned the word stress to you, stress doesn't affect your blood pressure, isn't that the component? that could cause your blood pressure to go up during the day and maybe the horn, I mean, you can't put it in a position where for hours you had my blood pressure high, which you really shouldn't have, so the question refers to more than one blood pressure reading. and what is important and how to know what blood pressure is the most important and how often you should take it to get the most accurate result and also the effect of stress itself, so that effective stress permeates much of what I He said blood pressure in the clinic the single routine blood pressure in the clinic is not considered as accurate as other things so what are those other things?

It is not as accurate as home blood pressure readings in predicting risk. It is not as accurate as in-clinic blood pressure readings where you wait five minutes and then average three readings and use the average to assess risk. Routine clinic blood pressure is not as accurate as a 24-hour ambulatory blood pressure monitor, so the more readings you have, the better, the more accurate. is when you compare it to the gold standard, so the answer is the more data you have probably the better in terms of what is used in the clinic to evaluate what to do.

I think an average resting blood pressure in the clinic is probably the most accurate thing that we know or know how to measure blood pressure and when taking blood pressure from home this is a difficult thing because people come with very different modalities of To measure your blood pressure, some people have a sheet of paper with 12 readings. If you don't have time to sit there and average these 12, a healthcare provider wouldn't do it. I wouldn't blame someone for looking at a list of blood pressures at home and getting an idea of ​​what the average blood pressure is. at home based on that which is often what is used in a busy clinical practice, so what I am saying is that blood pressure varies throughout the day;

It certainly varies with stress in some patients, stress affects blood pressure much more than others. people, but I think that the average blood pressure wins, the more readings you have, the more important it is to take them all into account and, if there is any discrepancy, concentrate on the ones that are done in rest, I assure you that yes, in this De Pury, the moment when we arrest them and sitting there they come to the reader and their cuffs give different readings, very good ones, so the cuffs that are used in the clinic must be regularly calibrated routinely with a mercury manometer or a mercury Sigma. in Honor to give an accurate reading at that time, although the blood pressure in five minutes may change, but at that time it should give an accurate reading and most clinics will have routinely calibrated cuffs to use to measure blood pressure.

Number one, number two, blood pressure certainly varies over five minutes, but taking, if they're all at rest, the blood pressure, taking the average of those blood pressures is probably the most reliable thing to do instead of taking the most lowest or highest. Of those values, the third thing has to do with stress, so stress affects people's blood pressure very differently if you compare a resting blood pressure versus walking around the clinic, sit down and quickly take the blood pressure , that blood pressure may be lower than that of the rest of the blood. Blood pressure can be higher with the rest of the blood pressure, on average it is slightly lower, but it can be much lower or sometimes it can be the same or sometimes a little higher.

Each one is a little different, but you have to evaluate it. larger populations which of those types of measurements are the ones that are best associated and most closely associated with events that matter, so the cardiovascular risk for cardiovascular events and therefore the average wins the day rested a blood pressure wins the day and if you have home readings type Taking a gestalt of those readings at home is probably more accurate than just relying on the routine clinic blood pressure run, sit up quickly, stress, a call, assuming it's a calibrated cuff , if the cuff is not calibrated, everything I just said doesn't matter. the cuff needs to be calibrated and you don't trust uncalibrated readings for any of the above, so if you have a cuff at home and trust your clinic doctor, I would take your cuff to the clinic to have it calibrated where you can measure the blood. pressure in one arm with your cuff and the clinic blood pressure device in the other arm and then turn them over and do both and if they're both 10 millimeters of mercury or less, it's probably accurate, yeah, so measure, measure in house to theright. and clinic on the left and then flip it so it's home on the left and clinic on the right and if both comparisons are close enough then I would consider a calibrated bracelet if you don't have inherent trust in your care providers. blood pressure cuff then I would bring it up to your healthcare provider because it needs to be well calibrated so the question is are they accurate over a period of time as I don't have a good degree in biophysics and I don't work first Euler Packard, I'm probably the worst person to ask about scylla metric devices and their accuracy over time, the ones we've had in the clinic for a long period of time, so I guess they stay accurate over a long period of time Yes, so given the importance you raised for measuring blood pressure devices, two questions and the quality of the devices seem to vary quite a bit, do you know if you have any recommendations or is there a source where I can look up the accurate devices? , yeah, the same thing.

A second thing is that doctors have this different type of rapid pressure medicine. Can you have a kind of confusion? I will adjust the two questions separately, the first has to do with which device should be used at home because accuracy is important and the second question has to do with which classification of hypertension medications should I use because it could be important in terms of the different sleeves. they have at home there are several brands in which mm most of the bracelets that company sells are validated when I say validated there are three there are three governing bodies that actually do validation there is one in particular that I go for simply because I know the address of their website and I can look and see and they have a link to the blood pressure journal that they published their validated readings in.

That's the European Society of Hypertension protocol, it's called esh/IP, but there's a call for Several different agencies got together and came up with a standardized way to validate blood pressure, so some of the brands that my patients have and Some of the brands that appear on these validated lists are standard. It is a standard company. ' is another standard company Welch Alan is another standard company Philips is another standard company I would say probably the Omron devices are probably some of the most popular ones sold if you go for a home device you would get an upper arm device instead of a device and the reason I say this is because there are more validated arm devices than wrist devices, but most arm devices are validated and publish their validation data, so I have tended to trust that there are some companies, including Omron. and Whiting have something on their device that allows you to connect it via Bluetooth to your phone, so there is an app on your phone and that, depending on your provider, can transmit that data to your provider and at Stanford that is possible and it makes it more convenient. for that data to be transmitted so you don't have to record it and if you're really interested you know the European Society of Hypertension, their SH - IP protocol and I forgot what I think the international protocol is - it's a standard that was developed in 2010 and they have a website and they have a list of all the devices, whether on the wrist, on the upper arm, a link to the document, the blood pressure range that was validated in the age group that it was validated in in how many patients, was it validated by the company, the serial number, not the serial number, but the catalog number of the device, etc., so most Armor on devices are validated, most devices They are validated so it is likely that a popular brand has gone to the trouble of being validated because there is market pressure to do that and that is what I would use and then if you have any questions I would calibrate it with the testing device. your doctor.

The second question has to do with different types of medications, so there is a slightly longer answer, but there are many different types of antihypertensive medications and they are named according to their mechanism of action and there is an alphabetical term ABCD that is very useful, so we use it, as it refers to two types of drugs that work slightly differently, but work in a related way, one is called ACE inhibitors or angiotensin-converting enzyme inhibitors, the other is blockers angiotensin receptors and therefore inhibit the function of the angiotensin system, which is tested in the true class of drugs, the second, the B stands for beta blockers.

C stands for calcium channel blockers and D stands for diuretics or, simply put, medications that make you urinate more and eliminate the salt in your urine so that you reduce the salt in you and thus lower your blood pressure. Those are the four. Drug classes A, C, and D are considered first-line, so they are not beta blockers. When I say first-line medications, I mean patients who don't have any other doctors and who have high blood pressure and it's high enough that they have to take a medication. It's a potpourri of options and there is no right answer as to which medication it is. necessary for a patient, so I started with that saying that it's better to treat blood pressure with something than nothing, some people will certainly respond better to an angiotensin-converting enzyme. inhibitor versus a calcium channel blocker and people will have a variety of responses just like some people will respond better to salt or obstructive sleep apnea therapy or exercise or weight loss, but we don't test for evaluate how much response people will respond to a particular drug, so it has not been clinically realized that someone has a genetic score that indicates that their blood pressure will be lower if they take an angiotensin receptor blocker or that they have clinical criteria that indicate that this medication will work better. for them to lower their blood pressure, so this is often done empirically, so a doctor or care provider will use one of these three classes of medications as a first-line medication and then depending on the side effects , will evaluate whether you should and The response will evaluate whether to increase the medication or move to a second class and start using that medication.

There are some patients who have high blood pressure but also other conditions, so a good example is someone who has had a myocardial infarction or heart attack. Beta blockers are considered a medication given to patients after they have had a heart attack to prevent a second heart attack, so beta blockers also lower blood pressure, making it a perfect indication to kill two birds of a shot, so although beta blockers are not considered a first-line blood pressure medication, they are a perfectly reasonable first-line medication from a medical point of view. line but blood pressure agent for patients who have those conditions or patients who have heart failure or patients who have an arrhythmia a beta blocker is a very good first option for that type of patient there are other conditions conversely where the beta blocker angiotensin converting enzyme or old have a receptor blocker which is a a would be a good first line supervisor D chronic kidney disease would be that example of a condition or diabetes would be a very good example of a condition there are certain classes of medications that are better depending on your rest and their race and ethnicity, so African Americans will tend to respond much better to a diuretic than to a calcium channel blocker or an angiotensin-converting enzyme inhibitor, so it depends on the patient and other conditions, but there is some empiricism in the choice of medications and also the pattern that is used thereafter in terms of increasing synergy at low doses or maintaining synergy between multiple medications, I would say that this last strategy is probably more commonly employed now because our Population is aging and side effects play a much larger role. more important role in how we treat patients, so a lower dose of more medications is probably safer in avoiding side effects than a high dose of one medication before moving on to the second medication, so that strategy specific and what medication to use is more or less an open question, it's why I didn't want to spend.

I've already spent half an hour more. I didn't want to spend too much time on that particular question, but there are very clear conditions for which a medication is the first choice, but if there is no clear reason, there is no clear reason and a C or a D is like choosing your poison. , there is no way to know how good this proposition is in some sense. I've seen them sometimes say that category D in particular can also cause blood pressure to rise. sometimes they get very low, so they say, oh, should I drink while taking the medicine?

Let's not join zero 20 mg, let's go to 40 mg instead of staying at 20 mg, but let's go to this category D drug. No, partly partly yes, because there is no right answer. the proof is in the pudding the proof is in the response that patients have so lowering blood pressure to target is more important than the choice of medication if there is nothing driving the choice of medication if there is something driving the choice of medication a comorbidity a condition such as heart disease or a comorbid condition such as chronic kidney disease. Yes, then there are clear options for a first-line and even a second-line agent, but if there is nothing driving that choice, then it is the answer and it is a reactive strategy.

Know that we don't send out some kind of test that says the ACE inhibitor sensitive check will give you an ACE inhibitor, so a lot of times it's going to depend on the care provider's comfort level as to what they're going to choose first and so on. There is some empiricism that comes into play, but there are rules that we follow in terms of a great example is if you have a condition where on clinical examination or history one realizes that the swelling is a part de is part of what a patient has and they have high blood pressure, often they will look for a D or a diuretic because we anticipate that that will help reduce blood volume and reduce blood pressure in more than one of the other agents, but that is not It is always the case and we do not always have clues to help us sometimes there are blood tests that patients have that will determine the choice of medications sometimes you can kill two birds with one stone sometimes people have conditions with certain contraindications medications, For example, a thiazide diuretic is a very effective blood pressure agent administered by a nephrologist from left to right If you have a severe history of gout arthritis or a severe history of hyponatremia, most doctors or most care providers would do There would also be contraindications for certain medications, so it depends on the patient and what other conditions they have, but you know if that's all off the table in the empiricism of Spire, yes, and how does that relate to a home, so the question has to be has to do with coffee, so in this case I'm talking about caffeine.

Decaffeinated coffee doesn't matter, but caffeine can raise blood pressure, so it was a clinical trial, as an example, there was a clinical trial that I was a part of. We had to make sure that patients had a certain blood pressure or lower to be able to safely enter the clinical trial because the drug they were receiving, although beneficial for a condition, tended to raise blood pressure, so we had to make sure that they were under a certain target to qualify for the medication and patients came in and if their blood pressure was above a certain level and you asked them if you just had a cup of coffee, it's time in the morning, you probably got up very early and You drove all the time.

I was on my way to Stanford and needed something to pick me up in the car. Did you have coffee before you got here and they said yes? We would have to wait a little bit and then take the blood pressure again and it would be perfectly fine, so I use that example is that anecdote has a way of saying that caffeine can raise blood pressure acutely, so it affects the interpretation of the reading that you have, but if you were to take a great 24-hour reading on a population and say whether caffeine was a risk for hypertension or not, I would say it's not a big risk for hypertension, but if you looked at the individual reading and What decision is made about the individual caffeine reading doesn't matter, so it's an important part of the story. because certainly, if your blood pressure is below target and you just had a cup of coffee and you show up with your blood too high and you never drink coffee, you just drink it becauseYou came to Stanford and Starbucks was the only thing. open down the road, you probably don't want to be given a completely new medication that you're going to take every day for the rest of your life, so it does matter, but I'd say it's more important in the short term.

Of the risks I talked about, there were things that mattered in the long term. Modify your monitoring routine so as not to skew your readings. Take your blood pressure before drinking your cup of coffee. Maybe that's in the morning, when you get up earlier. You have to cough right after drinking coffee. If you want to monitor again during the day to get three readings in a day or two, how long do you want to wait? I would say between an hour and a half or two hours after the cup of coffee. it's perfectly fine, yes, if you drink coffee frequently during the day, I often use that as a substitute to start asking about sleep apnea, because if someone has become fatigued from not sleeping well at night because they have obstructive sleep apnea and feel like they need caffeine throughout the day to stay awake there is a reason behind all that caffeine and that's why we have diagnosed obstructive sleep apnea based on a history of excessive caffeine consumption so that's something I asked about if it's purely habitual and not something that is likely to change or and is there any reason to change, then I would simply measure it not immediately after the cup of coffee for yes, the question is: is there any amount that is considered excessive?

I do not know the answer. That question certainly a lot of coffee has other side effects for other things, so I imagine there is an amount that is considered excessive, but I probably can't tell you exactly what it is. This baby aspirin affects blood pressure in no appreciable way. right it's not a problem yes sir yes so the question is what is the correlation between heart disease and high blood pressure which is the chicken and which is the egg so we are nephrons and again I can make fun of the cardiologist because my wife is one of them, high blood pressure is a cause of heart disease, heart disease is not usually a cause of high blood pressure, in fact, severe heart failure usually occurs with lower blood pressure.

Yes, severe heart failure, can high blood pressure cause heart disease? It is usually not the cause. Another exception would be the rare case of coarctation of the aorta, which is not technically heart disease, but anatomically close enough to present with hypertension in the upper extremities and lower blood pressure in the lower extremities, which is actually not a heart disease per se, but it is the closest thing to it, where the heart would be the cause of high blood pressure; otherwise generally no, the heart is not the cause of high blood pressure, it is the effect, yes sir, the question is about smoking, so smoking is a risk. factor for atherosclerosis that can affect your risk of hypertension right, yeah, so blood pressure is Ohm's medical law, right, it's pressure is flow times resistance, so things that increase your systemic vascular resistance they will increase your systemic blood pressure for the same level of cardiac output yes ma'am so the question is about low blood pressure and heart disease so the specific type of heart disease that can be associated with lower blood pressure is heart failure systolic heart rate, so interestingly, the hypertension guidelines don't actually say that. what is considered too low blood pressure generally what is considered too low is when one has evidence of a lack of blood flow to the vital organs when the blood pressure is below that level, so it would be considered low blood pressure , so an example of that would be if you're dizzy you had a blood pressure of 105 systolic and a systolic pressure of 105 millimeters of mercury if that makes someone dizzy and that's probably too low for that individual if someone is perfectly asymptomatic with a blood pressure of 105 millimeters of mercury.

I wouldn't say that's too low. There are also patients, by extension, who have a blood pressure or systolic blood pressure of 90 to 91 millimeters of mercury who do not have any symptoms and that is perfectly fine for them. There are patients who have low blood pressure and have evidence of lack of blood flow to vital organs, so dizziness would be an example of low cerebral blood flow or profusion of cerebral blood flow. There are patients who have elements of kidney disease when their blood pressure is too low and we measure that in standard blood tests and we would do that.

We probably figure out that blood pressure isn't as low if that's the case and then there are other organs that can be measured in other ways to measure that and there are usually causes of low blood pressure specifically if it's more symptomatic, but we generally don't do that. Don't chase low blood pressure unless it's symptomatic or the number is just too low and I would say anything less than a systolic over 90 would be something that's out of the norm, but I don't want you to go away from here. Thinking that if your systolic blood pressure is 95 millimeters of mercury, something is wrong, it depends on the individual and certainly the more asymptomatic that patient is, the less likely that patient is that that blood pressure is too low, but the more symptomatic they are, the more probably that blood pressure is too low yes sir, I'm not a cardiologist, I don't talk about pots, so the question was about the pulse rate and most of these devices will also measure the pulse rate and the pulse has several complete series. from lectures that we didn't have time to get into, but in general, as a nephrologist, I don't pay much attention to screw speed, but it is important for certain things, just nothing that I had time to talk about today, okay, thanks guys. much appreciation