Blood Pressure: How High is Too High and How Do I Lower it Safely?
Blood Pressure: How High is Too High and How Do I Lower it Safely?
Blood pressure is the force that moves blood through our circulatory system. Dr. Robert Baron explains what the two numbers mean in a reading and when it’s too high. He also talks about strategies for lowering your blood pressure safely. Recorded on 10/30/2018. [1/2019] [Show ID: 34158]
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0:00 Start
3:16 Goals for Tonight
18:42 Accurate Office BP Measurement
23:06 Accurate Home BP Measurement
31:30 Summary BP Measurement 2018
35:20 Lifestyle Modifications for BP Control
41:28 Salt in the US Diet
49:31 Key Points of JNC 8
53:04 Evidence-based Medications
57:24 SPRINT: Results
59:26 NNT and NNH from SPRINT
1:16:41 Q \u0026 A
Content
0.122 -> (logo whooshing)
1.205 -> (melodic tune)
5.091 -> (gentle music)
16.21 -> - I'm gonna speak about one
of my favorite subjects,
18.74 -> which is high blood pressure.
21.33 -> And it's one of my favorite
subjects for many reasons.
23.77 -> I'm a primary care general internist
26.39 -> and it's by far and away,
28.08 -> the most common thing
that family physicians
30.89 -> and general internists and
other primary care clinicians do
34.6 -> in primary care practices is,
36.8 -> help patients with their blood pressure.
40.26 -> In addition, when we
look at worldwide health,
43.71 -> depending on which study you read,
46.47 -> there's some evidence
that high blood pressure
49.12 -> is the number one cause of
preventable deaths worldwide.
55.56 -> Others would argue tobacco is on that list
58.47 -> or maybe diet is on that list,
61.12 -> but certainly high blood pressure
63.04 -> is on the very, very top of that list.
66.16 -> If not first, then in the top three.
69.06 -> In addition in the United States,
70.62 -> we know that the rates of
heart disease and stroke
74.45 -> have been declining,
particularly heart disease.
78.09 -> And when we determine why that is,
81.57 -> we know that a lot of
the progress has been
84.64 -> from the way we treat
heart attacks and strokes
87.75 -> in the intensive care unit,
89.89 -> but over half of it is from
the way we work with prevention
94.19 -> of heart attacks and strokes
96.16 -> with the treatment of common
risk factors as we call them.
100.59 -> And the three most important, again,
102.56 -> are tobacco high blood cholesterol
and high blood pressure.
107.38 -> And again, you could
debate amongst those three,
109.92 -> which has had the most impact, but again,
113.24 -> treatment of high blood pressure,
114.5 -> control of high blood
pressure is on the short list.
118.74 -> Now having said all that,
120.96 -> another thing we know is that if you look
124.36 -> at population studies,
126.62 -> having a lower blood pressure is healthier
129.42 -> than having a high blood pressure.
131.7 -> And in fact, that relationship starts
134.87 -> at pretty low blood pressure levels.
137.34 -> In other words,
138.173 -> if your blood pressure
is even over 110, 120,
142.68 -> your risk statistically of
having a heart attack or stroke
147.24 -> begins to increase.
148.87 -> but it's a very small amount
for any given patient.
152.88 -> And despite that observational evidence,
155.21 -> that epidemiologic evidence,
158.03 -> we still have a tremendous
amount of controversy
161.35 -> about at what level to
actually begin treating it.
165.39 -> And if we're gonna treat
it, how to treat it.
169.41 -> And so that's my plan for tonight,
172.03 -> is to address some of
those larger questions,
176.43 -> both big and small related to
178.62 -> the management high blood pressure.
181.92 -> And I'll do that by first telling you
184.78 -> that I have no conflicts
related to the material
187.38 -> or any of the medications or devices
189.22 -> I'm gonna speak about tonight.
191.38 -> And this is my roadmap.
193.04 -> This is what I hope to
cover for you tonight.
196.21 -> I'm gonna begin with
something that's very basic,
199.37 -> which is how do I know if
I have high blood pressure
203.229 -> and the corollary to that is
204.81 -> what is the best way to measure it?
206.35 -> So we'll spend more time than
you expect on that subject,
210.8 -> 'cause it turns out it's
really, really important.
214.01 -> How can I lower my blood
pressure without medications?
217.74 -> When do I need medications?
219.25 -> At what threshold do we begin treatment?
222.37 -> Is it 160, 150, 140, 130, 120,
226.42 -> what's the right number?
228.32 -> And then if you do need treatment
for high blood pressure,
232.02 -> what medications are best?
235.09 -> We'll touch on all of those issues
237.21 -> and several others along the way.
240.79 -> Now, the other reason
why I chose this subject
243.06 -> for this year is because (clearing throat)
245.93 -> there's a tremendous amount of controversy
248.26 -> about this subject in
the medical community.
251.19 -> And I'll spend some time
discussing that with you,
254.85 -> but as you know, clinicians
now make a lot of decisions
259.03 -> in office practice,
(clearing throat) excuse me,
261.82 -> based on clinical guidelines.
264.49 -> And so many different groups of experts
267.3 -> write guidelines based on their reading
269.97 -> of the best evidence,
271.97 -> published the guidelines.
274.21 -> And we seek consensus.
276.69 -> And in many things that
we do over the years,
280.75 -> we've developed certain consensus around,
282.85 -> say screening for colon cancer,
285.02 -> or mammography between
the ages of 50 and 69,
289.14 -> or not doing pap tests under age 21.
292.31 -> These are things where we
as a community of experts
295.28 -> have come together
297.778 -> and almost all the
guidelines are consistent
300.85 -> and aligned with each other.
302.57 -> But as you'll see in the
treatment of high blood pressure,
305.83 -> we have guidelines that
are uniquely distinct
308.88 -> from each other and have major impacts.
311.85 -> So depending on how you read the evidence
315.36 -> and or how, which guideline
you choose to follow,
320.88 -> it really leads to big differences
323.06 -> in whether you need medications,
and if so, how many?
327.02 -> And so I'll try to touch
on all of those things.
334.02 -> So let's talk with
measuring blood pressure,
336.61 -> and this is a humbling topic to talk about
340.49 -> because you can get your
blood pressure measured now
343.99 -> in the supermarket and the
pharmacy and hair salons
347.262 -> and buy equipment from Amazon
350.85 -> or your local medical supply store,
354.18 -> the MAs on medical assistance,
356.07 -> so the nurses will check
it when you come in
358.48 -> to see the doctor or the dentist.
361.849 -> And so there's a lot of numb...
364.58 -> And you can of course check it at home.
366.49 -> And so there's a tremendous amount
368.33 -> of measurement of blood
pressure being done.
371.79 -> And the take home message
here is that we are very poor
376.16 -> at accurately measuring blood pressure.
378.89 -> And I recently wrote a paper on this,
380.81 -> and if you wanna read more
of the references there
383.7 -> asking the question,
385.54 -> which is how can we treat
blood pressure correctly
388.38 -> if we're not measuring it correctly?
391.25 -> And I would argue, we
don't measure it correctly
393.6 -> in any of the settings
395.03 -> in which we have the
opportunity to measure it.
398.57 -> So let me review that a little bit.
400.28 -> It's also humbling to
talk about this because
403.14 -> for any of you who are health
professionals, yourselves,
405.67 -> or have family members or
who are health professionals,
408.89 -> this is the almost the
first thing everyone learns.
412.68 -> And yet despite that, we
do it quite imperfectly
417.68 -> as a profession.
420.15 -> Now this is confusing because
422.11 -> there are three different ways,
424.43 -> they'll actually be a fourth
that I'll mention as well,
427.91 -> to measure blood pressure.
431.822 -> And it has to do with the
setting in which we measure it.
435.24 -> So the most common is you
go into someone's office,
438.77 -> a doctor, a nurse practitioner, whomever,
441.1 -> and they measure your blood pressure.
442.44 -> So that's called office measurement
444.04 -> and that's actually
been our gold standard.
446.78 -> So when we look at studies of treatment
448.69 -> of high blood pressure,
450.32 -> almost all of them have
used office measurement
453.43 -> as the gold standard.
455.76 -> But of course you can also
measure blood pressure at home.
459.08 -> And if you do that, (clearing throat)
460.56 -> if you include home measurement
462.66 -> as part of someone's regimen,
464.83 -> it turns out that the patients
end up using less medication,
470.52 -> but they also have less
good blood pressure control.
473.83 -> And so it's a little bit of a trade off
475.75 -> 'cause you tend to get
lower numbers on average,
479.14 -> when you measure at home,
and I'll say more about that.
483.1 -> And then the third option
is something we called
485.73 -> an ambulatory monitor,
487.55 -> and these have been around for decades,
490.3 -> but they're very underutilized.
493.05 -> And what they are as you would
wear a blood pressure cuff,
496.61 -> you could wear it for 24 hours or 18 hours
499.62 -> while you're awake,
501.15 -> it can be programmed to automatically
503.18 -> take your blood pressure
504.69 -> no matter what activity you're doing.
506.95 -> And it gives us an average
blood pressure done robotically,
512.15 -> if you will, over the course
of 18 hours or 24 hours.
516.79 -> And it turns out from
some recent evidence,
519.68 -> these ambulatory monitors,
this 24 hour average,
524.17 -> correlates to the best with
strokes and heart attacks.
526.93 -> And when I use that abbreviation CVD,
528.95 -> I'm talking about cardiovascular disease,
531.5 -> which includes heart attacks and strokes.
536 -> Now we have these three
different categories
538.31 -> of blood pressure, and it turns out
540.55 -> they measure different things
541.81 -> and they don't correlate all
that well with each other.
545.32 -> Sometimes in medicine, if we
comparing diagnostic tests
548.71 -> with each other,
550.24 -> we compare them to a gold standard
552.36 -> and we can describe
553.61 -> the characteristics of the test,
555.47 -> which patients they might miss,
557.5 -> which patients they might over detect.
559.89 -> The problem here is that we don't know
561.54 -> which is the gold standard.
563.24 -> So we can compare them to each other,
566.57 -> but we don't really know
what is the objective truth.
570.27 -> So what we end up with is
three different strategies
574.68 -> for measuring blood pressure
that we have to interpret
578.76 -> each one on its own.
582.13 -> Now the medical community
has reached consensus
586.64 -> on how to measure correctly.
588.28 -> And the last time I counted
590.03 -> from one of the official guidelines
593.78 -> that I'll make reference to later,
596.02 -> there were 19 different
elements that constituted
600.35 -> an accurate blood pressure measurement.
603.35 -> Now I've summarized these into eight,
605.96 -> but it includes all 19.
607.25 -> I've just combined a few.
609.23 -> But what I want you to
do as I go through these
612.62 -> is think about the last time you had
615.92 -> your blood pressure measured in the office
619.49 -> and which of these were followed
621.66 -> and which of these were not.
623.52 -> And that's really the punchline.
626.02 -> And we'll also get to
the second punchline,
628.5 -> which is when you're measuring
631.03 -> your own blood pressure at home,
633.64 -> you should do the same things
that I'm about to describe
636.7 -> that the clinician
should do in the office.
639.16 -> And so again, think about
how you're measuring
641.82 -> your blood pressure at home
643.56 -> and which of these best
practices you're following.
648.39 -> So one of the most important things
649.99 -> is that you need to be
seated for five minutes
652.24 -> before the blood pressure is taken.
654.51 -> So in my office, what happens often
657.628 -> the patients have trouble.
659.57 -> They're late for the appointment.
660.73 -> They're having trouble finding parking,
662.16 -> there's traffic around the office.
664.65 -> They finally get in
665.81 -> the parking spots are painted too tight.
669.26 -> Finally, get it in, you
almost hit the posts.
672.27 -> You rush upstairs, the elevator
stopping at every floor.
676.08 -> You finally come in,
676.913 -> there's still time to get
checked in by the nurse.
680.02 -> And she sits you down
and she starts reviewing
682.09 -> your chief complaint and starts
reviewing your medications.
685.83 -> And while she does that,
686.92 -> she's cranking up the blood pressure.
688.783 -> (audience laughing)
689.87 -> So there are about six things wrong
691.56 -> with that particular scenario.
693.96 -> And one of the most important
is to allow the body
697.93 -> to equilibrate before the blood pressure
700.64 -> is measured.
702.87 -> While the measurement is done,
the back should be supported,
706.46 -> and the feet on the ground.
708.27 -> Now, even in my own office
where I see patients personally,
712.49 -> I cannot do this because
I have an exam table.
715.28 -> And the way the exam table is positioned
717.67 -> to the cuff on the wall, I don't...
719.9 -> It's not an exam table,
it goes up and down.
722.55 -> So my patients don't
have their back supported
724.81 -> and don't have their feet on the ground,
726.3 -> even in my own office.
728.26 -> So you're not supposed to
take any caffeine exercise
730.97 -> or smoking for 30 minutes.
732.45 -> I'll say more about caffeine later.
735.52 -> Caffeine is not associated
737.38 -> with high blood pressure
chronically, but in the short term,
742.08 -> if you drink a cup of coffee right now,
744.64 -> it can increase the blood pressure.
747.3 -> My personal favorite is no talking.
749.74 -> So no talking by the
patient and no talking
752.3 -> by the person who's
taking the blood pressure.
755.291 -> So this is one, certainly that
these initial blood pressures
759.58 -> were often done incorrectly.
761.74 -> There should be no
clothing under the cuff.
764.96 -> Another common mistake.
766.69 -> So often your blood
pressure is being taken
768.53 -> in a public setting,
769.46 -> the cuff is put on over your clothes.
772.07 -> That's incorrect.
775.743 -> The arms should be supported
at the level of your heart,
778.73 -> the atrium, one of the
chambers of the heart.
781.11 -> So usually on a table or
on the clinician's arm,
783.76 -> but up in this relaxed position.
786.93 -> And probably the most important of all,
788.9 -> or one of the most important of this list
790.7 -> is a correct cuff size.
792.83 -> And so most of the blood
pressure cuffs you purchase,
796.25 -> if you don't go out of your way to ask
801.15 -> for a larger cuff will be too small.
805.05 -> And that's true for because
of obesity and overweight.
808.94 -> That's true cause of excess skin folds.
812.42 -> That may be true cause
of excess muscle mass.
815.58 -> But in our society, in my practice,
817.75 -> I hang up the large cuff,
I take out the other ones
820.43 -> I set them aside, and I
never use them all day long.
823.18 -> 'Cause the large cup
will fit almost everyone.
826.33 -> And if the large cuff is too large,
830.82 -> you do not get a falsely low value.
834.96 -> The only thing that all of
these different factors do
838.95 -> is give you a value that's too high.
842.17 -> So basically what we're
doing is over diagnosing
845.34 -> high blood pressure by
the incorrect measurement
849.05 -> of blood pressure.
850.36 -> And that's true in the office,
and that's true at home.
853.64 -> So again, that's a long list.
855.91 -> It's a lot of time spent
on this simple subject,
858.23 -> but I think it's on the very short list.
860.7 -> One of the most important things we can do
863.14 -> to improve the way we
manage high blood pressure.
866.48 -> And as I implied, this
is also true at home.
869.57 -> So remember all of these things,
871.21 -> when you're checking
blood pressure at home,
873.17 -> these are the best practices
that you should follow at home.
877.02 -> - [Man] Can you comment regards how tight
879.405 -> to make the way cuffs?
881.84 -> - Let's take your questions at the end
884.82 -> for the editing purposes.
885.83 -> But the question was how
tight to make the cuff.
888.43 -> The cuff is automatically, it's marked
891.43 -> where to the fit it around the arm.
895.11 -> Uninflated it should be comfortable.
897.47 -> And when you're inflated, it gets tight.
899.28 -> and the tightness is derived
901.07 -> by how many millimeters of
mercury you inflated to.
905.34 -> So if your blood pressure,
907 -> if I think your blood
pressure might be 180,
910.07 -> then I need to go higher than
180 in order to come down
913.88 -> to get that measurement correct.
916.42 -> And if I get up to 200, it's gonna hurt.
919.34 -> If I think your blood pressure is 130,
921.36 -> I might go up to 160 and that would feel
924.81 -> on the comfortable side of tight.
927.2 -> So the cuff itself just
comfortably around that.
930.75 -> So it stays on the arm
by itself basically.
934.614 -> and then the pressure is what
determines that feeling that,
938.13 -> ooh, that hurts a little
or that's too tight.
941.86 -> The other controversy is
what blood pressure to count.
947.12 -> And what do you write in the chart,
948.55 -> or what do you write on your log at home?
952.54 -> Most of the guidelines
in the United States
954.98 -> talk about doing repeated
measurements and averaging them.
959.18 -> That's okay.
961.008 -> It's a little hard to do
the arithmetic in your head.
962.79 -> You know, you have to
be, slick with the...
965.69 -> Write down the value 'cause you'll forget.
968.04 -> Write down the second
value than average the two
970.13 -> that one can do that.
972.01 -> In the office it gets a
little more complicated
974.19 -> because the medical assistant or nurses
976.55 -> taking a blood pressure or two
979.03 -> then do I count his or hers
981.12 -> and then my own and average those two,
983.51 -> or they do it twice myself
and just average my two.
987.35 -> So there's a lot of uncertainty
about the best practice.
991.84 -> But it turns out, and I'll
show you this in a few slides.
996.32 -> It turns out that the acceptable
way, and this is true.
999.7 -> The Canadians do it this way.
1001.61 -> And in fact, most of the quality measures
1004.01 -> in the United States do it this way,
1005.94 -> is you can record the lowest value.
1008.15 -> So if you've taken it two or three times,
1010.56 -> you don't have to average,
but you record the lowest one.
1014.51 -> And our definition of blood
pressure control is determined
1018.33 -> using the lowest value.
1020.64 -> So many people make an
error on that as well.
1025.38 -> Now all of these things can
lead to a dramatic increase
1028.63 -> in blood pressure, and
I'm talking dramatic.
1031.5 -> 30 points millimeters of mercury.
1035.02 -> On average people report about 20,
1038.89 -> but some people it can
be substantially higher.
1044.48 -> So if your blood pressure is high,
1048.57 -> one of the first things
to do is repeat it.
1052.22 -> And in fact, a study was just done
1054.49 -> that was published earlier this year.
1056.63 -> And it was a study from
20 different clinics
1059.4 -> in a city like ours.
1061.87 -> And the medical assistants were instructed
1064.89 -> on these 19 features that I just reviewed
1067.67 -> of taking the blood
pressure best practice.
1070.75 -> And then they were instructed
with one other thing,
1072.92 -> which was, they were told if
the blood pressure is elevated
1077.29 -> over in this case, 140/90, take it again.
1082.1 -> And just by taking it a second time,
1085.1 -> the blood pressure was under 140/90,
1088.56 -> over a third of the time.
1090.78 -> So repeating the measurements routinely
1093.82 -> give you a lower measure measurement
1096.62 -> in part maybe because that resting
1099.18 -> is happening now a little bit,
1100.69 -> that's settling down that
we talked about and so on.
1104.29 -> So that's a very easy trick,
is just take it again,
1108.04 -> and you can record the
lower of the values.
1113.19 -> And as I talked about, this
is an ongoing controversy
1118.28 -> and different practices
do this differently,
1120.34 -> but I think when you
look at quality measures
1122.88 -> in the United States,
1123.713 -> including the ones we use
from the federal government
1125.76 -> that are called HEDIS Measures
1129.33 -> or like the Kaiser's do in
their population studies
1132.31 -> and so forth,
1134.11 -> the quality community accepts
the lowest measurement
1137.14 -> when two or three values have been taken.
1140.24 -> But the guidelines still often talk about
1142.42 -> averaging multiple measurements.
1146.99 -> Now there's also something
that's not common.
1150.13 -> I call it research grade measurement.
1153.73 -> And the way this was done in
this one particular study,
1158.61 -> which I'll come back to
called the SPRINT Study,
1162.28 -> the Systolic Blood Pressure
Intervention Trial,
1165.95 -> they had the medical assistant
take the blood pressure
1168.84 -> akin to the way we would in the office,
1171.2 -> and then they would instruct the patient
1173.68 -> to go into a quiet room that
was with them dim lighting.
1178.53 -> They would have an automatic
machine, a robotic machine,
1181.96 -> to take the blood pressurement.
1183.58 -> They would sit for five minutes.
1185.94 -> They had three automated measurements
1187.85 -> with some pause in between.
1190.07 -> There was no human in the room.
1192.8 -> All the different 19 features
were being adhered to,
1196.75 -> and the blood pressures were averaged.
1199.48 -> And what was fascinating about this
1201.98 -> is that when they compared
the values they got
1205.4 -> in the dark room with the
automated measurement,
1209.1 -> it was 12 and a half points
lower than what the nurse got
1214.52 -> in their advanced high
blood pressure setting.
1217.553 -> This is a place where people
were coming to see experts
1220.13 -> to participate in a big study.
1222.23 -> And even in that big study
1223.96 -> compared to the robotic dark room,
1226.55 -> the dark room was 12
and a half points lower.
1230.21 -> Keep that in the back of your mind,
1232.19 -> because you'll see this
study turns out to be
1235.5 -> one of the major studies
that has influenced
1239.23 -> some of the guidelines that
suggest we should treat people
1242.31 -> at much lower values.
1244.5 -> And so it's a little bit of a catch 22.
1248.25 -> If you're gonna use the
research grade measurement,
1252.21 -> which is 12 points lower,
1254.3 -> then treating at a lower
threshold may be okay.
1257.38 -> But if you're gonna measure it
1258.46 -> the way we normally measure it,
1259.8 -> then may be treating it
at the higher threshold
1262.27 -> is also okay.
1263.37 -> And you'll see where the
guidelines fall out in that regard.
1267.04 -> But remember this robotic measurement.
1269.57 -> And what we may see in the future
1272.77 -> is that more people will move to this.
1274.62 -> It would be pretty easy to
do in a busy office setting.
1277.46 -> You just set up, you need an extra room
1281.702 -> and a robot, just an
automated machine basically
1284.47 -> and it's pretty easy to do,
1287.73 -> but it's not how it's currently done.
1291.228 -> (clearing throat)
1292.061 -> Now, the other issue that has
become part of common practice
1298.08 -> led by consumers and also device makers
1302.72 -> is to measure the blood
pressure outside the office.
1306.13 -> And there is a consensus about doing this.
1309.8 -> In fact, the U.S. Preventive
Services Task Force
1313.3 -> as early as 2015, so several years ago,
1316.62 -> as part of their official recommendations
1318.67 -> for blood pressure management,
1320.31 -> suggested that measurements
should be a pain
1322.84 -> outside the clinical setting,
1324.28 -> meaning outside of the physicians,
1328.95 -> nurse practitioners office,
before starting treatment.
1332.54 -> This is not common practice.
1334.62 -> Most clinicians continue to treat
1336.55 -> based upon their own measurement,
1338.6 -> but it is interesting
because many of us follow
1341.41 -> the U.S. Preventive Services
Task Force guidelines
1343.56 -> for other things like cancer screening.
1346.07 -> But in this case, it hasn't really been
1348.73 -> fully integrated into a common practice.
1352.75 -> People use home measurement
for a variety of things,
1356.93 -> but it's not that common
to use it routinely
1361.57 -> as a second test, if you will,
before you begin treatment.
1365.98 -> However, in England, that's what they do.
1368.25 -> And so the blood pressure
has to be checked
1370.42 -> outside of the office before
the patient gets treated,
1373.27 -> especially with medications.
1378.25 -> All right, let me move next
to home measurement briefly.
1383.25 -> I've already said several
things about this,
1385.407 -> and it turns out this is
not well standardized.
1388.23 -> You all, if you're measuring
your blood pressure at home,
1390.55 -> you're all doing it in your
private time and space,
1394 -> and I have no idea how you're doing it.
1396.59 -> I barely know how my medical
assistant is doing it,
1399.32 -> but I certainly don't
know how you're doing it.
1402.07 -> Although one good trick is to
bring your machine in with you
1406.35 -> when you see your clinician
and demonstrate to them
1409.96 -> how you are taking it,
1411.13 -> which gives you the
opportunity to also make sure
1414.03 -> the cuff size is correct, that
your technique is correct,
1417.6 -> the machine is a well
standardized machine,
1420.42 -> correlates with the office
measurement and so on.
1423.07 -> So that's not a bad little trick
1425.75 -> if you wanna be a little bit more precise
1428.44 -> in your home measurement.
1430.47 -> It's also not fully evidence-based,
1431.78 -> and what I mean by that is
when patients are assigned
1436.28 -> blood pressure treatment
with home measurement
1438.83 -> and compared to blood pressure treatment
1441.01 -> without home measurement,
1442.42 -> and that's the only extra intervention,
1446.84 -> there's no benefit of home measurement.
1449.64 -> Now that's a little misleading because
1452.877 -> if you did a real comprehensive program
1456.24 -> of blood pressure control,
1457.59 -> that included pharmacy
involvement and home checks
1462.82 -> and frequent checks and combination pills
1465.32 -> and things like that,
and home measurement,
1467.67 -> that is part of an integrated
comprehensive plan,
1470.45 -> home measurement can be a useful tool.
1472.34 -> But when it's been isolated,
1474.3 -> as the only extra thing that's done,
1476.62 -> it doesn't help that much.
1478.52 -> It's a little bit like
checking blood sugars
1481.38 -> in people who are on pills for diabetes,
1485.32 -> where, now I'm not talking
if you're taking insulin,
1487.95 -> then you must check your home blood sugar.
1489.55 -> But if you're just taking
pills, depending on the pills,
1493.4 -> many patients do not need to
check their home blood sugar,
1496.32 -> and it's not associated with
a very significant change
1499.12 -> in diabetes control.
1500.8 -> And this is analogous to that.
1504.55 -> Correct home monitoring requires all 19
1508.19 -> of those other elements.
1509.97 -> So everything that I
suggested in the office
1512.52 -> you should do at home and therefore again,
1517.61 -> bringing your equipment in and
having the nurse or physician
1521.67 -> watch you take your blood pressure
1523.25 -> is a good way to make
sure that your own skills
1525.83 -> are up to best practices.
1528.56 -> And again, things like correct equipment
1532.63 -> is also extremely important.
1535.62 -> And that's complicated now
1537.22 -> 'cause there's so much new equipment.
1539.66 -> Many, many of the new devices
have not been well-validated.
1543.25 -> And so people are selling
all sorts of things
1545.69 -> on fingertips and wrists and so forth.
1548.62 -> And many of those measurements
have not been validated
1551.63 -> in rigorous studies.
1552.61 -> And when they have been
studied in rigorous studies
1554.83 -> do not correlate particularly well
1556.9 -> with the measures that I'm discussing.
1560.97 -> The correct timing is interesting
1562.67 -> because as I mentioned with
the ambulatory monitor,
1566.32 -> it's around the clock.
1568.07 -> And so you could argue
that doing home measurement
1571.73 -> that mimics the ambulatory
monitor might make sense,
1574.78 -> and that's not a bad way to do it.
1577.73 -> So rather than checking it every day
1580.29 -> or every day twice a day, or whatever,
1582.68 -> you could argue, maybe I'll
check it five times a day,
1585.9 -> one day per month,
1587.9 -> akin to my using an ambulatory monitor,
1591.46 -> so getting a measurement
throughout the day,
1593.91 -> because the blood
pressure goes up and down
1596.18 -> in a diurnal rhythm over the
course of a 24-hour period.
1600.49 -> It's highest in the morning
and it's lowest in the evening.
1603.66 -> So if you're checking your
blood pressure after dinner,
1607.93 -> especially after a glass
of wine, kids are asleep,
1611.6 -> everything's copacetic,
1614.18 -> you're gonna get a lower
blood pressure then,
1617.11 -> than if you check it when you
first wake up in the morning
1620.53 -> before you've taken your medications.
1623.65 -> So that's important to know.
1624.95 -> And so what our current guidelines are,
1627.81 -> you can do this all day, one day,
1629.72 -> every now and again model,
1631.7 -> but the standard
recommendations are to check it
1635.84 -> in the morning before
you take your medications
1638.34 -> and then before dinner,
1640.54 -> as a way to frame the higher and lower.
1646.3 -> But I don't recommend.
1647.71 -> They're very, very few patients
1649.05 -> who need to do this every day.
1652.079 -> You get too much information,
you get too worried about it.
1654.43 -> It's not adding value,
1655.97 -> but it is something to do
occasionally and keep track of it.
1661.56 -> And again, share that
information with your clinician.
1665.89 -> Home measurements, as I mentioned,
1667.35 -> are lower than office measurements.
1668.88 -> And sometimes people talk
about having different normals,
1673.32 -> but the relationship is
not uniformly predictable.
1675.89 -> So I can say if your blood
pressure is 145 in the office,
1679.15 -> it's 135 at home.
1681.24 -> It could be, but it might not be.
1683.35 -> So it's not a fixed relationship.
1685.59 -> On average, it's lower, but
in any individual patient
1688.88 -> or any individual measurement,
1690.61 -> the correlation is a little
bit better than a coin flip,
1694.82 -> but not a ton better.
1696.11 -> It's about 60 or 70% correlation.
1700.86 -> And as I mentioned, when
you isolate home management
1703.82 -> as the only intervention,
1705.85 -> the evidence has shown little impact.
1709.3 -> All right, the final part of this section
1711.61 -> is to talk about ambulatory
blood pressure monitoring.
1715.64 -> And again, this is a machine
you would normally pick it up
1719.11 -> from the cardiology suite
1721.61 -> or where you might get
an electrocardiogram
1723.61 -> or maybe an echocardiogram,
or certainly a Holter monitor.
1727.88 -> That's where these live.
1729.41 -> They're relatively inexpensive.
1731.49 -> Medicare will cover these,
1733.63 -> especially if the right
diagnosis is put down,
1737.62 -> the right diagnosis being
elevated blood pressure,
1740.64 -> 'cause you're using it to help decide
1742.61 -> whether someone has hypertension,
1744.47 -> which is the disease,
versus not hypertension.
1748.57 -> So Medicare will pay if you
use elevated blood pressure.
1751.99 -> And again, I already
described how it works,
1754.39 -> you can program it to
do anything you want,
1756.53 -> typically it's several times
an hour while you're awake.
1759.55 -> And usually a few times at night,
1761.44 -> most people can sleep through this.
1764.17 -> Again, it's slower than the office,
1765.81 -> but the relationship is unsettled.
1768.14 -> But as I mentioned, the recent studies,
1770.74 -> including a very thorough review
1772.91 -> by the U.S. Preventive Services Task Force
1775.78 -> has suggested that it predicts
1779.06 -> amongst a population of people,
1781.33 -> who's gonna get into trouble
with cardiovascular disease
1785.36 -> than the other tools.
1787.16 -> That is to say it's makes
blood pressure measurement
1791.19 -> the most predictive risk factor
for heart disease and stroke
1794.96 -> compared to office measurement
or home measurement.
1798.87 -> So it's available, it's safe.
1802.23 -> It's not that expensive, but
we use it quite infrequently
1806.64 -> in modern American medicine.
1808.07 -> And I think one of the things
I favor is using it a bit more
1813.24 -> because misdiagnosing someone
with high blood pressure
1817.42 -> usually means a lifetime of medications.
1819.49 -> 'Cause it's rare once people get diagnosed
1822.2 -> with high blood pressure
that they get undiagnosed
1824.89 -> with high blood pressure,
1825.79 -> that requires a little bit of courage
1828.31 -> on the patient's part
and the clinician's part.
1834.38 -> It also is the best
way to detect something
1836.52 -> that's been called
white coat hypertension.
1839.35 -> And this is that syndrome
where your blood pressure
1841.76 -> is high in the office
and low everywhere else.
1844.94 -> That does exist.
1846.56 -> It's more common in women than men.
1848.33 -> It's more common in young than old.
1850.39 -> It's more common in Caucasians
than African-Americans.
1854.55 -> So it does exist.
1855.67 -> It's most common in young Caucasian women.
1859.26 -> And when you see an elevated
blood pressure in the office
1862.2 -> as a young woman,
1863.98 -> which is very important
to diagnose correctly
1866.24 -> because of the impact it
can have on pregnancy,
1869.29 -> but it can also be over-diagnosed.
1871.1 -> And that's a setting where
careful home measurements
1874.04 -> or an ambulatory monitor can
be particularly important.
1877.86 -> You can also use it to monitor treatment
1880.64 -> and for some other purposes.
1883.53 -> So in summary, this simple task that we do
1890.222 -> from the pharmacy to the hair salon,
1892.31 -> to your home, to my office,
to the cardiologist's office,
1897.21 -> turns out to be a little
bit more complicated
1899.28 -> than we thought.
1901.86 -> And from a clinician point of view,
1904.06 -> we talk about really
rethinking the office workflow.
1908.75 -> I think who's ever
taking the blood pressure
1910.84 -> it's good to repeat the measurement.
1914.71 -> Whoever you're working
with should think about
1917.26 -> whether to take averages
or record the lowest value.
1921.1 -> Home measurements are good.
1922.96 -> We probably do it more than we need to,
1924.97 -> but less accurately than we need to.
1927.08 -> So if you're gonna do it and do it well,
1929.46 -> but maybe a little less often,
1932.09 -> and make sure you're
following best practices,
1934.81 -> particularly things like cuff
size breasts and so forth.
1938.71 -> And again, similarly,
the ambulatory monitor
1941.28 -> should be used more.
1942.55 -> Probably doesn't need to
be used in every patient
1945.11 -> or even every patient with
nuance and high blood pressure.
1947.83 -> But we certainly, whenever we
have a sort of a tiebreaker,
1952.651 -> and a patient doesn't wanna
be on meds, for example,
1956 -> and the clinicians thinking, eh, I mean,
1958.02 -> you should be on meds,
1959.26 -> perfect situation to
get another data point
1962.747 -> and get the average under the curve
1964.287 -> and the area under the curve
and use the ambulatory monitor.
1969.86 -> All right, so I'm gonna move on.
1971.79 -> That's what I have to
say about measurement.
1974.32 -> I think that's the longest
section of the talk
1979.63 -> but I think probably the most
impactful of the way it would,
1983.68 -> if done correctly, change
how we as clinicians practice
1988.3 -> and how you manage your
own blood pressure at home.
1993.386 -> (clearing throat)
1994.27 -> I wanna speak briefly about
treating high blood pressure
1997.88 -> without medications.
2000.42 -> This is something I've been interested in
2002.1 -> since early in my career.
2003.78 -> As many of you know,
2004.613 -> I studied nutrition before
I came to medical school
2006.88 -> and I've looked for the interface
2009.06 -> between nutrition and internal
medicine and chronic illness
2012.36 -> for my entire career.
2014.18 -> And one of the first studies
I ever participated in
2016.87 -> was a study that compared
what we call nonpharmacologic
2021.14 -> or non-drug therapy for high
blood pressure with drugs.
2025.75 -> That study, it was a great study.
2027.48 -> We had 300 patients that we recruited
2030.53 -> and we managed them very carefully.
2032.01 -> My job was to teach them how
to manage it without drugs.
2035.28 -> And at the end of a year of followup,
2038.49 -> the drugs won hands down.
2041.13 -> And in fact, the NIH had funded that study
2043.95 -> and they had funded about a
dozen others at the same time.
2046.63 -> And every single study
showed the same thing,
2049.41 -> the drugs outperform
non-drug treatment uniformly
2052.82 -> across the board.
2054.36 -> So medications are very effective
2056.54 -> for lowering blood pressure.
2058.81 -> We'll see more about that in a minute.
2060.41 -> And nonpharmacological therapy
is a relatively modest tool
2065.57 -> in your toolbox across all patients.
2070.07 -> But for individual patients,
it can be the answer.
2073.62 -> And so in the study,
2075.28 -> we were looking at the
average blood pressure
2077.21 -> between 300 patients
or 150 on the non-drug
2080.55 -> and 150 on the drug,
2082.31 -> but for an individual patient,
2084.48 -> the things I'm about to talk about
2086.05 -> can be extremely effective
and can either slow
2090.33 -> the need to take medications
2093.06 -> or allow you to take one less medication,
2098.705 -> or in some cases completely,
2101.2 -> treat the blood pressure
without medication.
2103.63 -> So it's a very potent tool in the toolbox
2106.3 -> for a motivated patient,
2109.2 -> especially one who has certain
clinical characteristics.
2113.43 -> Now, one of the most important
2115.81 -> or predictive characteristics
2117.52 -> is if you're overweight or obese.
2120.25 -> And so if your weight is high
2123.31 -> and you have high blood pressure,
2125.11 -> and there's a close correlation
of those two things,
2128.93 -> then weight loss is uniformly effective
2133.02 -> at lowering high blood pressure.
2134.71 -> So if a patient can lose 20 pounds
2137.74 -> and keep it off for a year or so,
2139.87 -> the blood pressure will go down a ton
2142.63 -> and it's worth at least
one or two different pills
2146.97 -> or classes of medications.
2149.31 -> The problem is that it's
really hard to lose 20 pounds
2153.07 -> and keep it off.
2154.8 -> But for the patient, who's at that point
2157.42 -> where you're ready to do that,
2160.45 -> then weight loss always works
at lowering blood pressure.
2164.43 -> And it's quite well sustained.
2165.8 -> Now, eventually as you gain weight,
2167.85 -> or even if you kept the
weight off as you age,
2170.55 -> you're at risk of the blood
pressure drifting upward again
2173.26 -> over time,
2174.56 -> but you can delay medication
for quite some time
2178.59 -> if you're effective at
treating high blood pressure
2181.5 -> with weight loss and
those that are overweight.
2185.79 -> Alcohol can also raise blood pressure.
2188.93 -> You don't have to become a
teetotaler if this is the case,
2192.35 -> but if your blood pressure is high
2194.23 -> and you're a moderate
to heavy alcohol user,
2199.23 -> three, four, five drinks a day kinda class
2201.65 -> is the way some of
these studies were done,
2204.06 -> and can get down to one drink a day,
2206.56 -> the blood pressure can
come down quite nicely.
2210.24 -> Although the amount you'll see is smaller
2212.68 -> than with weight loss,
2213.83 -> but it's a real effect, but
there aren't that many patients
2218.62 -> who drink that much and are
willing to stop drinking
2221.78 -> just for a little bit of
blood pressure control.
2224.27 -> They'd rather take a medication
I think in many cases.
2229.13 -> Salt intake is something
I'll say more about,
2232.83 -> but we've recommended salt restriction
2235.16 -> or sodium restriction for
decades for high blood pressure.
2238.06 -> It's part of our public
health recommendations
2240.14 -> for a healthy diet,
2242.63 -> and the numbers are complicated
2244.34 -> and I won't review them
particularly, but in general,
2249.851 -> restricting sodium can
lower blood pressure
2253.02 -> very effectively, but
only in some patients.
2255.87 -> And it's probably somewhere
about a third to a half.
2259.49 -> And so it's a very
effective tool for treatment
2262.33 -> of high blood pressure in some patients,
2265.15 -> but it's more controversial
about whether the whole society
2268.83 -> needs to lower our salt intake.
2270.91 -> In other words, 'cause a lot of patients
2272.85 -> with high blood pressure won't benefit
2275.61 -> from sodium restriction,
2277.65 -> but if you have high blood pressure
2280.42 -> and if you're on a high sodium intake,
2283.29 -> and if you're African
American in particular
2287.5 -> or older in particular,
2289.44 -> both of which are associated
with reduced clearance
2292.8 -> of sodium by the kidney.
2294.53 -> So reduce handling of a
salt load, if you will,
2299.72 -> then sodium restriction
can be quite important.
2303.84 -> Some of the recommendations in the past
2305.51 -> have recommended extreme
sodium restriction
2307.81 -> that doesn't work and may be dangerous.
2310.67 -> And again, moderate sodium
intake for most people is fine,
2315.15 -> but it's a tool in your toolbox
2318.46 -> if you wanna give it a try,
2320.17 -> especially if you're not overweight,
2322.66 -> and if you don't drink that much,
2324.96 -> then it's third on the
list and it's worth a try,
2327.92 -> and I'll come back to that in a minute.
2330.23 -> There's something called the dash diet,
2331.82 -> which has been around
for about 15, 20 years,
2334.55 -> which is basically just
a heart healthy diet.
2336.61 -> So all the principles
of eating a healthy diet
2340.88 -> with mostly plants, not too much real food
2347.05 -> and relying on mostly
fruits and vegetables,
2350.51 -> whole grains, small amounts
of meat, fish, and fowl,
2355.36 -> nuts and oils, and so on,
2356.91 -> a Mediterranean type diet
or a heart healthy diet,
2360.26 -> that's been shown to lower blood pressure.
2362.99 -> And in fact, it's additive
with sodium restriction.
2368.46 -> So if you combine a heart healthy diet
2370.77 -> and sodium restriction,
2372.09 -> the blood pressure goes down further.
2374.82 -> Physical activity can
lower blood pressure.
2376.82 -> We recommend physical
activity for everyone anyway,
2379.81 -> as I like to say, physical
activity is Biblical
2382.75 -> and that means you should
do it six days a week
2384.73 -> and one day of rest.
2387.53 -> The recommendations are
30 plus minutes a day.
2390.92 -> And that if you're start sedentary
and you get to that point
2394.39 -> can lower the blood pressure
2395.5 -> by five to 10 millimeters of mercury.
2399.12 -> And as I implied earlier,
2400.6 -> a habitual caffeine consumption
or coffee consumption
2404.32 -> is not associated with the
risk of high blood pressure.
2407.43 -> In fact, coffee consumption
seems to be the Teflon substance
2411.49 -> that it's not been shown to
be bad for almost anything,
2415.21 -> but certainly the studies
that have looked at mortality,
2418.52 -> heart disease risk,
cancer risk, stroke risk
2421.41 -> and the like, have shown
caffeine to be not associated
2426.04 -> with bad outcomes in general.
2429.09 -> Now clearly it can make you irritable.
2432.35 -> It can give you GI problems.
2434.61 -> It can cause atrial
fibrillation in some people.
2437.05 -> But in general, when
you look at populations,
2439.66 -> caffeine as a fatigue, mitigator,
2441.89 -> as we call it with the
residents is safe and effective.
2447.32 -> Once upon a time when I was
a nutrition graduate student,
2450.01 -> I used to say, and I had
a slide that said this,
2452.93 -> it was a while ago,
that a third of the salt
2456.43 -> in the human diet comes
naturally occurring in food,
2459.79 -> a third comes from food processing
2462.27 -> and a third comes from us
as consumers at the stove
2466.87 -> or at the table.
2467.97 -> And that now is just totally wrong.
2471.89 -> We've evolved over those 40 years
2473.85 -> to the point where our diets are different
2476.75 -> and our sodium sources have
changed to the point now
2481.33 -> where processed and restaurant foods
2483.67 -> account for almost 80% of our salt intake.
2487.67 -> So still a small amount from
naturally occurring in foods
2492.14 -> and still some at home.
2494.65 -> But if someone tells you
or someone suggest to you
2497.41 -> or for your own reading suggests
2499.05 -> that you wanna be in
a lower sodium intake,
2501.89 -> worrying too much about
what you do with the stove
2504.61 -> or the table is most
likely the wrong tactic.
2509.09 -> And what you need to do
is not purchase anything
2513.01 -> in a bag or a box or a can,
2516.45 -> unless it says in really big letters,
2518.73 -> low salt, because anything
in a bag or a box or a can
2522.19 -> is high salt,
2523.87 -> unless it says otherwise.
2525.89 -> And so the whole story of
when you go to a big market,
2531.08 -> only shopping on the
outer aisle of the market,
2533.74 -> where the produce is and
the dairy and so forth
2536.57 -> makes very good sense.
2537.76 -> So don't limit your consumption
of things in general
2542.16 -> that are in a bag, or a box, or a can,
2543.85 -> if you're concerned about
your salt or for that matter
2546.67 -> current dietary recommendations.
2550.17 -> Secondly is restaurant food
2552.21 -> and other package and prepared foods.
2555.876 -> So a lot of the services that
are out there delivering food,
2559.84 -> but particularly restaurant food.
2561.71 -> I don't know if any of you have gotten
2563.42 -> into the game of weighing
yourself every day
2566.71 -> and the night after you
went to your favorite,
2569.61 -> whatever restaurant that's
particularly high in soy sauce
2572.92 -> or whatever, and your
weight goes up four pounds
2579.1 -> and you say, "This is not possible.
2581.577 -> "I didn't eat anything yesterday."
2583.44 -> But then you realize
you went and had sushi
2585.5 -> or your favorite Thai food restaurant.
2588.98 -> And it was all because
of the sodium intake.
2591.04 -> So those changes in weight
are all salt and water,
2594.35 -> so a couple of days later it'll come off.
2597.24 -> But that's showing you how
much sodium is in that food
2602.56 -> that you ate at the restaurant.
2604.1 -> And the worst culprit
of course is fast food.
2606.94 -> So not to pick on Asian cuisine,
2608.98 -> but fast food is by far and
away the biggest culprit here.
2614.12 -> And of course in our
society, that's a concern.
2618.84 -> So sodium restriction is if you're eating
2620.81 -> a mostly plant diet and you're
eating your nice tomatoes
2625.87 -> and you wanna put some salt on it
2627.71 -> and that makes you more tomatoes,
2629.15 -> that's a good thing to do.
2631.07 -> Or if it helps you consume your
lettuce and your big salad,
2635.35 -> do it because that's healthy,
2638.72 -> but going to a fast food
restaurant or buying food,
2640.89 -> that's in a bigger box or can is not.
2644.5 -> All right.
2646.1 -> I'm gonna move next
2647.21 -> to some of the clinical
questions that are most
2652.09 -> on the mind of clinicians
working with patients
2656.19 -> with high blood pressure in
terms of medication management,
2659.46 -> labeling and so forth.
2661.87 -> And most of what we know
about high blood pressure
2664.19 -> over the course of the last decades,
2666.92 -> most of all of my career,
2668.71 -> have been from an entity
2670.4 -> called the Joint National Commission.
2672.45 -> And this is a NIH brought
together panel of experts.
2677.12 -> They meet every five to seven years or so,
2679.75 -> and they come up with
different recommendations,
2682.317 -> and over the years they've defined
2683.94 -> what's a normal blood pressure.
2685.35 -> They've recommended certain
types of drugs over other drugs
2688.15 -> and so on.
2690.13 -> And the most recent one
was a few years ago.
2693.18 -> It was the eighth version of this,
2695.86 -> and they asked three questions
2698.2 -> and this was good because they were
2700.96 -> three really good questions,
2702.27 -> the three questions
that we all care about,
2704.05 -> which is, does treatment of blood pressure
2708.01 -> at a certain level of elevation work?
2712.83 -> If so, how low should I treat it?
2716.15 -> Good questions.
2717.66 -> And third, what medication should I use?
2720.28 -> Does it matter?
2721.82 -> And what they did was,
2722.89 -> which was different
than the seven previous
2726.3 -> Joint National Commissions,
2728.18 -> is they only looked at what we call
2729.84 -> Randomized Clinical Trials,
2731.36 -> which is the highest level of
medical scientific evidence,
2735.09 -> where there's a control group,
2737.26 -> a blinded evaluation of large
populations of patients.
2742.89 -> And there had been several dozen of these
2745.45 -> that met the criteria
for various questions
2748.17 -> related to high blood pressure.
2750.31 -> And they came out with
nine recommendations.
2752.41 -> I'm not gonna read them all.
2754.72 -> I'll summarize.
2756.77 -> The one that was most surprising,
2759.32 -> I wouldn't call it controversial at first,
2761.28 -> but it was definitely a surprise,
2764.24 -> was the recommendation that
for people over 60 years old,
2769.9 -> which is a lot of the population
2771.77 -> that has high blood pressure
in the United States,
2774.63 -> that we could use 150 as our
cut point rather than 140.
2781.06 -> So this was really great
news for primary care
2784.76 -> and really great news for patients.
2787.57 -> Because if it meant we can let
people ride a little higher,
2791.65 -> then that means one less
medication, typically,
2794.65 -> less side effects, less cost and so on.
2796.68 -> So this was a very good recommendation,
2799.8 -> very popular recommendation
2801.31 -> amongst the primary care community,
2803.74 -> but others didn't react so
favorably as I'll show you.
2808.26 -> And they recommended lowering it below 150
2810.98 -> and also lowering a second
number, the lower number,
2813.88 -> the diastolic blood
pressure to less than 90.
2817.47 -> So this was a surprise, but favorable,
2821.68 -> and it wasn't pulled out of the sky
2824.15 -> and I'm not gonna review this,
2825.52 -> But each of these abbreviations
2827.96 -> stands for a really big,
well done, publicly funded
2832.68 -> randomized clinical trial of the treatment
2835.58 -> of high blood pressure.
2836.94 -> And so they looked at a
very large body of evidence
2839.93 -> in order to make this conclusion.
2841.54 -> So it was very, what we
would call, evidence-based.
2847.77 -> The other recommendations
were not as controversial.
2852.58 -> They said for everyone else under 60,
2855.67 -> then you should use 140 as your cut point.
2858.83 -> Or if you're treating both the high number
2863.14 -> or the low number using
90 as the low number.
2868.06 -> I should just point out it
turns out that the high number
2871.61 -> is more important than the low number.
2874.19 -> When I was in medical
school, that wasn't the case.
2877.15 -> We mostly focus on the lower number,
2879.9 -> what we call diastolic hypertension.
2882.04 -> But it turns out that
systolic hypertension
2885.19 -> is the most predictive of
cardiovascular disease,
2888.7 -> heart disease and stroke.
2891.63 -> At the time these studies
were being analyzed,
2896.83 -> the diabetes community
was trying to suggest
2900.28 -> that lower values would be better,
2903.26 -> but they reviewed the
evidence carefully and said,
2905.42 -> even in diabetics, it
doesn't really matter.
2908.08 -> People with kidney disease,
2909.38 -> CKD stands for Chronic Kidney
Disease, didn't matter,
2913.95 -> You could use 140.
2916.02 -> And people were pushing
2917.2 -> that in the African American community,
2919.14 -> where there was a lot of risk
associated with hypertension
2921.33 -> that lower numbers might be better.
2923.04 -> They looked at that literature
and said it doesn't matter.
2925.71 -> And so basically they
concluded that 140/90
2929.24 -> was fine for everyone,
2931.76 -> that there were many patients over 160
2934.68 -> that you could let ride a
little bit and drift up to 150.
2939.25 -> Although they also said if
the patient was under 140
2942.167 -> and well-controlled, that was fine too.
2944.84 -> So you were given some flexibility
for people over age 60.
2951.09 -> The medications they
recommended were four,
2954.64 -> and previous recommendations
have favored one class
2959.33 -> over another.
2960.59 -> They were a little bit more agnostic,
2962.55 -> gave us a smorgasbord of four medications,
2967.61 -> except it was really four
ways to get to three,
2971.29 -> because two of them
shouldn't be used together.
2973.53 -> So the four categories are thiazides,
2976.5 -> which are water pills,
2977.92 -> weak water pills, but
which have independent
2981.945 -> blood pressure lowering effect.
2983.9 -> CCB stands for Calcium Channel Blockers.
2986.63 -> I'll give you the specific names
2987.94 -> of some of these in a minute.
2989.83 -> Those work.
2992.889 -> ACEI stands for ACE Inhibitor
2995.6 -> and other I'll give you the names.
2997.83 -> And the fourth category are
angiotensin receptor blockers,
3001.74 -> or ARBs,
3003.78 -> and they also can be used
as the first class of drugs.
3009.88 -> The one corollary here was not
to use ACE and ARB together.
3015.98 -> So you could use ACE or ARB,
either first, second, or third,
3019.85 -> and then thiazide first, second, or third
3022.56 -> with calcium channel blockers
for a second or third.
3025.99 -> So that was sort the modern menu.
3028.94 -> And that was again good for patients,
3032.43 -> 'cause there were a lot of
medicines in these classes,
3034.4 -> good for physicians,
3035.29 -> 'cause they're medicines
we knew how to use.
3040.23 -> You'll note or you may note
that one class of medicine
3043.5 -> that's not on this list are beta blockers.
3047.53 -> And beta blockers have been
used for high blood pressure
3050.19 -> for many, many years,
3051.15 -> they're very good for other conditions.
3054.1 -> But when studied compared
to these four drugs,
3056.99 -> they're not as effective
as a single therapy.
3060.77 -> But that's a little misleading
because they're excellent
3064.86 -> as the third or fourth drug
3066.73 -> or they're excellent if you
need it for something else.
3069.91 -> So it still lowers your blood pressure,
3072.23 -> just not quite as evidence-based
3074.81 -> in terms of preventing
strokes in particular
3077.6 -> as these other four classes of medicines.
3080.16 -> But it's still on the list,
we use it all the time.
3082.43 -> It's very effective way
to lower blood pressure,
3084.64 -> but just not as the first or second drug
3087.4 -> as the main blood pressure
lowering treatment.
3092.8 -> And something that not everyone knew,
3095.32 -> although it's been in the
literature for several decades
3098.88 -> is that ACE inhibitors and
angiotensin receptor blockers
3102.44 -> do not work as well in African Americans
3105 -> as the other classes of drugs.
3106.61 -> So they specifically went
out of their way and said
3109.33 -> for African Americans,
3110.45 -> we recommend thiazides or
calcium channel blockers first.
3114.25 -> Again that's also a little misleading
3116.85 -> because many patients need,
3118.42 -> most patients need more
than one medication.
3121.01 -> And again, once you've
gotten to drug number three,
3125.08 -> you begin to go to back to
ACE and ARB very quickly
3128.12 -> in African Americans,
3129.44 -> but you would start
with thiazide diuretics
3132.16 -> or a calcium channel blocker
as your drugs of first choice.
3135.94 -> And in kidney disease,
3137.1 -> that's the one disease with
specific recommendations,
3140.57 -> especially if you're spilling
protein in the urine,
3144.7 -> then ACE inhibitors and
ARBs have a long history
3147.53 -> of helping preserve kidney function.
3149.89 -> But that's really more in the context
3152.27 -> of having chronic kidney disease
3154.32 -> than just bland essential hypertension.
3158.33 -> So those were the recommendations
3160.29 -> and we read this and said,
all right, that's sensible.
3163.33 -> They asked the right questions,
3165.07 -> they looked at the right body of evidence.
3167.9 -> These are patient-centered,
good for primary care,
3172.12 -> everything was good.
3173.61 -> And then the sky fell.
3176.442 -> (audience laughing)
3178.92 -> But these are the medicines that,
3180.73 -> just to show you some of the names,
3182.2 -> these are not the brand names,
3183.53 -> these are the generic names
or the chemical names,
3186.7 -> but you may still recognize them
3188.12 -> 'cause many of these medications
3189.34 -> have been around for decades.
3191.62 -> They're all generic, they're inexpensive.
3193.93 -> they're on everyone's formulary,
3195.2 -> not necessarily all of
them in each category,
3197.15 -> but one from each category
is on everyone's formulary.
3200.59 -> And so it's pretty easy to find
an ACE inhibitor that works.
3203.46 -> An enalapril or lisinopril
are pretty common.
3206.54 -> Angiotensin receptor blockers.
3208.6 -> Losartan is probably the most common.
3210.71 -> Valsartan is the one that had
a little bit of imperfections
3213.88 -> in the synthesis.
3215.3 -> So that's been out of circulation of late,
3219.18 -> but there are others in that class.
3222.12 -> The calcium channel blockers,
3224.12 -> amlodipine is a common one
3226.73 -> for high blood pressure.
3227.69 -> Diltiazem is another one.
3231.92 -> And then the thiazide-type
diuretics in the United States
3234.53 -> by far and away, the most
common is hydrochlorothiazide,
3238.05 -> although some of the others also work.
3240.63 -> So again, lots of choices, they're cheap,
3243.98 -> they're easily available.
3245.2 -> Doctors and nurses know how to use them
3246.96 -> 'cause they've been around forever.
3248.61 -> And so it's a good list.
3251.45 -> And then there is,
3252.55 -> I'm not gonna show you,
3253.47 -> but there's of course, 15
other categories of medicines
3257.95 -> that high blood pressure
experts and others can use
3261.16 -> if you need more than
three classes of medicine,
3264.62 -> although most patients do not.
3268.21 -> So then what happened,
3269.09 -> is soon after the guidelines came out,
3271.61 -> a big study was published,
3272.99 -> and I've already made reference
to this, the SPRINT Study.
3275.27 -> This was the one with the
robot in the dark room,
3278.77 -> measuring blood pressure.
3280.28 -> It was a really well done study.
3282.19 -> It was at almost 10,000 men and women.
3284.92 -> They were over age 50.
3286.99 -> They had a predesignated
group that were over age 75.
3291.07 -> So it was well done.
3292.62 -> To get into the study you
needed a blood pressure
3294.54 -> over 130, which was fine,
3297.18 -> and you needed to have a
high cardiovascular risk.
3301.24 -> And I'll explain that more in a moment,
3303.52 -> but it's an important
part of this conversation.
3308.61 -> Interestingly, they did not accept people
3311.37 -> with diabetes into the SPRINT Study.
3314.16 -> And that was a little bit puzzling,
3315.97 -> unless you knew that in the year or two
3319.41 -> before the SPRINT Study was being planned,
3322.61 -> there had been another big study
3325.11 -> funded by the National
Institutes of Health,
3327.01 -> so a very well done, randomized trial
3329.71 -> that compared 140 versus one 120,
3333.89 -> the two blood pressures,
3336 -> in patients with diabetes
to see which was better,
3339.19 -> and there was no difference.
3341.1 -> And so the conclusion was
that 140 was as good as 120,
3346.97 -> and of course that made it
much easier to treat patients
3349.7 -> 'cause again, it was one
or two less medications.
3351.96 -> Each medicine lowers your
blood pressure about 10 points
3355.24 -> or so on average.
3357.206 -> So 20 points is a couple of meds.
3360.98 -> So that was sort of weird
because we already knew
3363.41 -> that in diabetes, it
didn't make any difference,
3365.56 -> but they were doing the study again,
3367.16 -> but had to exclude patients with diabetes.
3369.38 -> So it was a little bit funny
the way that played out.
3375 -> But it does mean that
the results of the study
3377.23 -> do not apply to patients with diabetes.
3379.52 -> Who of course are one of
the groups of patients
3382.95 -> for whom treatment of high
blood pressure is most important
3386.17 -> 'cause they're at high risk
of strokes, heart attacks,
3388.01 -> kidney disease, and so on.
3390.08 -> They compared people to get,
3391.66 -> they randomize people to 120 or 140
3394.75 -> similar to the diabetes study.
3397.1 -> It took an extra medicine
to get people under 120.
3402.11 -> And it turned out it was
hard to get people under 120.
3404.41 -> The average was actually 121,
3406.29 -> which means on average,
about half the patients
3409.11 -> couldn't get below 120,
3411.11 -> even though they were
getting free medicine,
3414 -> being seen by their clinician regularly
3417.12 -> more frequent than you would see someone
3418.73 -> in a normal clinical practice and so on.
3421.83 -> So that was interesting.
3423.04 -> Also that people couldn't
actually get less than 120,
3426.69 -> especially this cohort of
somewhat older patients.
3432.45 -> And this is the diabetes study.
3433.88 -> I won't go over it in detail,
3436.05 -> but again showed that
there was no difference
3438.73 -> between 120 and 140
before the SPRINT Study.
3444.45 -> Now, the SPRINT threw us a curve ball
3446.52 -> because the results were positive,
3448.6 -> that is to say when they
looked at all the events
3454.81 -> associated with high blood
pressure, that is stroke,
3457.37 -> heart attack, non-fatal
stroke and heart attack,
3460.21 -> death from stroke and heart attack,
3462.25 -> it turned out that there were less events
3464.76 -> in the group that was treated to 120.
3467.04 -> So this was a positive
study suggesting that 120
3470.17 -> was better than 140.
3472.36 -> But this was a little counterintuitive
3475.62 -> 'cause we already had six or seven studies
3477.89 -> that I showed you 10 slides ago
3480.44 -> that said, it didn't really matter.
3482.13 -> We had this big diabetes study
that said it didn't matter,
3485.55 -> but here was this new
study that said it matters.
3490.054 -> And then the hooker was that it also led
3493.85 -> to less mortality that people
died less so often at 120,
3498.27 -> then one 140.
3499.77 -> So this created two
different conversations.
3503.01 -> So there's a group of people who thought
3505.21 -> that SPRINT was the end all,
3508.3 -> and that affected the
way you look at this.
3510.15 -> Other people looked at this
is an unexpected result.
3513.58 -> We're not sure what it all means.
3516.422 -> And the conversation
continued and got louder.
3522.64 -> There were a lot of side
effects on the SPRINT Study.
3525.48 -> These were things they looked
at carefully in advance.
3529.89 -> There was 67% more risk.
3531.72 -> And these were serious side effects.
3533.59 -> The criteria for this was side effects
3535.78 -> that the clinician
thought was serious enough
3538.42 -> to send the patient to
the emergency department
3540.84 -> or might be life threatening.
3542.49 -> That was the way the criteria was defined.
3544.85 -> So these are real low blood pressure.
3547.46 -> 67% more syncope, that is passing
out, losing consciousness,
3551.79 -> a third more of blood
chemistry abnormalities,
3555.61 -> a third more and kidney
problems, two thirds more.
3558.8 -> So there were a lot of side
effects, but nonetheless,
3563.3 -> the overall effect was beneficial.
3567.05 -> And it's a little hard to
explain the concept here,
3571.14 -> but there's something in medicine
3572.95 -> when you think about a lot,
3574.17 -> which is called the
number needed to treat.
3577.01 -> And I'll show you this
graphically in a couple of slides,
3579.9 -> but basically it's a way to put the odds
3585.51 -> of you personally benefiting
from an intervention.
3589.3 -> So remember these studies are
in populations of patients,
3592.82 -> but now you and I are
sitting across the table
3595.29 -> deciding what to do for you.
3598.19 -> And so what's the likelihood
that you will benefit
3602.53 -> given what we know about these
populations that benefit?
3606.7 -> You're with me on this?
3608.13 -> It's a confusing subject, but
it's a way to put some numbers
3613.23 -> on the concept of better versus worse,
3616.96 -> and quantitated
3618.13 -> so that people can make
individual decisions.
3621.92 -> And I'll show you this graphically,
3623.04 -> it'll be clear in a minute.
3624.9 -> But in general, the number needed to treat
3627.64 -> was about roughly a hundred,
3630.09 -> depending on what you're
measured over three years.
3632.76 -> So that's about 300 over
the course of any one year.
3637.76 -> So it means that if you and I
are sitting across the table
3640.5 -> from each other, the odds are 299 to one
3643.36 -> that you're not the one
that's gonna benefit.
3646.87 -> You're with me on this?
3647.84 -> So the population
benefits, but you may not.
3653.78 -> In fact, the odds are you won't.
3657 -> And that's just the way
medical science works.
3662.15 -> Similarly, the number needed
to harm is about the same.
3666.35 -> So we get some benefit, we get some harm
3668.79 -> and you'll have to decide
for you, which is better.
3673.73 -> Now, of course, in the
way this study was done,
3676.37 -> the benefits are better
than the harms, right?
3677.9 -> The benefit included heart
attacks, strokes, and death.
3680.55 -> And the harms, the harms are things like
3684.72 -> feeling lightheaded and falling down
3687.33 -> and having an abnormal blood test.
3689.24 -> So they're not the same,
3691.34 -> but it is worth noting that
the frequency was similar.
3695.85 -> These are all comments I've already made.
3698.6 -> And the last bullet though,
3700.21 -> is that when you look at
how the SPRINT Study applies
3706.7 -> to the community at large, to all of you,
3710.56 -> statistically, they're only
about one out of six of you
3713.89 -> that would meet the criteria
to have been a subject
3718.71 -> in the SPRINT Study.
3721.07 -> In other words, whether
it's age or other diseases
3727.12 -> or what your cardiovascular risk was,
3730.19 -> whether you had diabetes,
3732.18 -> all those things were
factors that determine
3735.16 -> whether you can enter the study or not,
3737.15 -> and only one out of six patients
with high blood pressure
3740.5 -> were able to enter the study.
3741.95 -> So again, the generalized stability
3743.61 -> to the community at large is modest.
3747.9 -> And here are some of the risk factors.
3749.877 -> And so there was no one who had diabetes,
3752.21 -> no one with stroke, no one was frail,
3754.45 -> and no one who was, let's
just say under age 50.
3757.09 -> And as I mentioned, there was free care,
3758.84 -> frequent visits and so forth.
3761.2 -> And this very careful measurement
3762.94 -> that was lower than the usual
measurement, if you remember.
3766.2 -> Then the other thing that
was really important to know
3768.47 -> is that these were very high risk patients
3771.85 -> and that many of you have
probably gone to websites
3776.26 -> and measured your 10-year risk
of cardiovascular disease,
3779.36 -> of having a stroke or a heart attack.
3781.94 -> There's a very good
one on the Mayo Clinic,
3784.98 -> it's called the Mayo Clinic
Statin Decision Site.
3789.95 -> If you just Google Mayo Clinic Statin,
3792.84 -> it comes up,
3793.8 -> and you can put in your
various risk factors
3796.17 -> and calculate your 10-year risk.
3798.01 -> And we use it in clinical
practice a lot to decide
3801.01 -> who needs a statin drug
for them for their risk.
3805.32 -> But it's also relevant
in this conversation
3808.44 -> about high blood pressure.
3810.3 -> And in fact, to enter this study,
3812.16 -> you needed a 10-year risk of 15%,
3815.82 -> and in fact, most people had 20%.
3818.52 -> If you've had a heart attack,
3820.59 -> your risk of having an event
in the next 10 years is 20%.
3824.73 -> So 20% is a high number
in this conversation.
3828.77 -> It's like, you've already
had a heart attack.
3831.03 -> And so these are people
3832.24 -> who are on the fairly far along spectrum
3835.33 -> of risk of cardiovascular disease.
3838.91 -> And here's a cartoon.
3840.826 -> It doesn't project super well,
3843.96 -> but what this is trying
to say is bring to life
3848.04 -> that concept of number needed to treat.
3852.27 -> And what I mean by this is,
3854.96 -> so each little gray box
represents one person.
3859.63 -> And if we have, say on
the left hand side here,
3862.54 -> a thousand people,
3865.42 -> we can show who are then
treated for three years
3870.46 -> to a blood pressure goal
of 120, rather than 140,
3873.18 -> based on the data from the SPRINT Study.
3875.81 -> We know that 16 of them
will not have a heart attack
3880.25 -> or stroke in the three year period.
3884.79 -> It's the same as the
number needed to treat.
3886.77 -> I've just done some arithmetic
and made it a cartoon.
3891.5 -> But the point of this, the
way to think of this, again,
3893.73 -> if you think about odds,
3895.6 -> if you started as one of the gray people,
3898.5 -> the vast majority of the
gray people stay gray
3901.69 -> after three and a half years
3902.89 -> of being on two and a
half medicines, right?
3906.02 -> Only a very small number become blue.
3910.54 -> And that's that idea that
what happens in populations
3914.13 -> is different than what happens
in an individual patient.
3918.285 -> You're with me?
3919.13 -> So this is a very intriguing way
3922.01 -> to think about medical interventions.
3924.59 -> And you can do this kinda
chart with anything.
3927.28 -> And we do it with cholesterol,
3928.67 -> we do it with a lot of
cardiovascular management,
3931.01 -> but you can do this with
lots of other things.
3934.01 -> So if you have pneumonia
from pneumococcal disease,
3939.92 -> and I give you penicillin,
almost every one of you,
3943.04 -> maybe 80% of you will get better, right?
3946.24 -> So the number of boxes,
this would all be blue.
3949.09 -> If this were talking about
pneumonia and penicillin,
3951.82 -> but now we're talking about
treatment of a risk factor
3954.91 -> to prevent events over a period of time.
3957.61 -> And the number of people
benefit one by one is much less.
3962.7 -> And so this is an important concept.
3965.68 -> And again, just to balance it,
3968.07 -> almost an equal number were harmed.
3969.75 -> Although to be fair, the
benefits are more important
3974.51 -> than the harms, but the harms are real.
3976.63 -> And again, take home point here,
3978.66 -> most people started gray and stay gray.
3982.49 -> Very few people change as a
result of this intervention,
3986.5 -> even though everyone has
to take the medication.
3990.85 -> All right, so let me close
this part of the conversation
3994.56 -> and we can then take some questions.
3997.6 -> The long and the short of
it is this study came out
4001.07 -> and then started and has
continues to this day,
4005.75 -> a debate in the medical
community about what to do.
4008.8 -> And so the cardiologist took this study
4011.42 -> and came out with some
guidelines that said,
4014.29 -> I'll show you them in a minute,
4015.4 -> we should follow these guidelines.
4017.45 -> And then just around the same time,
4019.88 -> the primary care community,
4021.1 -> the internal medicine community
4022.3 -> and the family medicine committee
4023.86 -> looked at the guidelines
and said, you know, actually
4025.9 -> we like the Joint National
Commission guidelines.
4028.47 -> We like 150 if you're over age 60,
4031.34 -> for everyone else 140,
4034.1 -> But the cardiologists said
something totally different.
4037.41 -> They said that if it's over
130, you should be treated,
4043.27 -> 140 everyone should be treated
4045.14 -> and 130, if you're at high risk.
4047.58 -> And that anyone over 120,
4051.07 -> we would call an elevated blood pressure.
4054.06 -> So it totally changes the
conversation from 140 to 120
4059.02 -> based on the results
of this one big study.
4065.03 -> And so these are what
their recommendations are
4067.41 -> for treatment, basically saying
4069.41 -> if you've already had a heart attack,
4071.77 -> then we should treat you
using 130 as the cut point.
4077.49 -> If you're at very high risk
of having a heart attack,
4080.25 -> we should treat you at 130,
and if you're at lower risk,
4083.87 -> less than 10%, then 140 is okay.
4087.69 -> And so that's now the debate.
4090.55 -> We have the 130 and 140 school,
4094.17 -> and we have the 140 and 150 school.
4097.34 -> And we're all just caught in the middle,
4099.42 -> and we have two groups
of really smart people
4101.73 -> looking at the same studies
4103.34 -> and drawing completely
different conclusion.
4108.06 -> Now, to try to sort this out,
4110.14 -> there've been a couple of studies of late.
4111.7 -> There was one just published this week.
4113.06 -> I don't have a slide from,
4113.99 -> but it's consistent sort of
with what I'm gonna show you.
4118.4 -> But this was a very nice study
that was published this year
4121.32 -> that looked at all of the
studies of high blood pressure,
4123.96 -> was 70 different studies,
300,000 patients,
4128.62 -> included men and women 60 years old.
4132.75 -> And basically they tried
to answer the question of,
4137.89 -> does it matter what the blood
pressure is when you start,
4142.08 -> when you start treatment.
4143.87 -> And basically they looked at
all the studies and they said,
4147.15 -> and the star here, the asterisk means that
4151.23 -> the results are significant.
4153.09 -> And what they showed is
that if your blood pressure
4155 -> is over 160 and you treat
it, treatment works.
4159.35 -> There's a 7% reduction in mortality
4162.43 -> and a 22% reduction in
cardiovascular events.
4166.62 -> So everyone agrees with that.
4167.563 -> If it's over 160, it should be lowered.
4171.07 -> 140 to 160, this study showed it works.
4175.55 -> So if it's over 140, it works.
4178.67 -> I will note there was a
paper published this week
4181.65 -> that just showed even between 140 and 160.
4183.883 -> It's not so clear that it works.
4186.051 -> (audience laughing)
4190.1 -> If it's less than 140, it doesn't work.
4194.77 -> So even though blood pressure
becomes a risk factor
4198.12 -> at low levels, if you're less
than 140 when you treat it,
4203.63 -> you don't get any benefit
from that treatment
4205.98 -> according to these 70 studies.
4208.55 -> So over 160 it works, over 140 it works,
4211.86 -> although now we have
a little debate there,
4213.72 -> but under 140, it doesn't work
4216.4 -> with the one possible exception in people
4218.73 -> who have heart disease.
4219.7 -> CHD stands for coronary heart disease.
4221.93 -> So if you already have had a heart attack,
4224.23 -> then it's reasonable to treat at 130,
4229.54 -> which is what the
cardiology guidelines say.
4232.54 -> And then what happened
after this conversation
4235.11 -> is that the family
physicians independently
4237.98 -> in the internist, again,
looked at their data
4240.47 -> and all the recommendations they say,
4241.927 -> "Well, what do we think?
4242.797 -> "Are we gonna go along with
the cardiology guidelines?"
4245.13 -> And they both said no.
4246.95 -> So we're gonna stick to the guidelines
4248.82 -> we published a couple of years ago,
4251.44 -> and still stick with a
150 if you're over age 60
4256.15 -> or 140 for most patients.
4259.99 -> It's also worth noting
that if you use 120,
4262.95 -> if use the guidelines that the
cardiology guidelines suggest
4266.95 -> that half the population is now labeled
4269.27 -> as having hypertension.
4271.09 -> And you know, that just doesn't
have face validity, right?
4273.99 -> It doesn't make sense that
all of us would be sick.
4279 -> - [Man] 46 means I'll
act like a (indistinct).
4280.721 -> (laughing)
4281.618 -> (audience laughing)
4284.57 -> - That half the population
would be hypertensive.
4290.23 -> So my final thoughts, and
then we'll open it up.
4294.47 -> We talked about measuring
blood pressure differently
4297.3 -> in the office, with carefully
following the 19 guidelines.
4303.34 -> I would say if you're a
patient in an office like that,
4307.35 -> you should ask the clinician
to retake your blood pressure
4310.24 -> if the first measurement is high.
4312.53 -> Sometimes it's not feasible to do that out
4315.33 -> where the medical assistant
took the blood pressure.
4318.28 -> But maybe when you get in to
see your personal clinician,
4323.15 -> that would be a time to have
the blood pressure taken again
4326.1 -> in a close to correct method as possible.
4329.86 -> I think it's excellent
to do home monitoring,
4333.02 -> Get a good machine, something
that fits over the arm,
4336.79 -> don't play with the
wrist fingers and so on.
4339.44 -> Make sure it covers your arm
4341.45 -> the way the dimensions are supposed to.
4345.38 -> Many of you will need a large size cuff,
4347.71 -> which takes an extra conversation
4350 -> with who's ever selling you the machine,
4353.26 -> and then sit comfortably,
have your arm be unclothed
4358.5 -> and so on, as we discussed
before you take it.
4361.52 -> Take it before breakfast,
before your medications,
4364.05 -> and take it before dinner.
4367.93 -> Consider ambulatory monitoring
4369.62 -> for those who are in a toss up zone
4371.87 -> you're just not sure what to do,
4373.26 -> especially after this talk.
4376.085 -> And so an ambulatory monitor
is a excellent tie-breaker.
4380.77 -> Gives you another complete,
relatively inexpensive,
4384.05 -> totally safe and noninvasive
way to collect information.
4390.53 -> And look at your cardiovascular risks.
4392.48 -> So you would be doing this anyway,
4395.53 -> if you're interested in
preventing heart disease or stroke
4398.72 -> with the use of aspirin or statins,
4401.63 -> 'cause we make those
decisions based on your risk,
4404.69 -> and what this literature now suggests
4407.34 -> is that we should be
using that risk prediction
4411.65 -> to help decide who should be
on blood pressure pills too.
4415.04 -> And if you're really low risk,
4418.14 -> then the benefit for you
may be a very high number
4423.37 -> needed to treat.
4424.65 -> In other words, it may
not be worth it to you
4428.09 -> to take the medications.
4429.67 -> And again, then it depends on side effects
4431.76 -> and preferences and costs and so on.
4435.99 -> I think 140//90 is a reasonable
compromise these days.
4440.88 -> I think, although this new paper, again,
4444.28 -> questions, whether that's maybe too low,
4447.56 -> but nonetheless, I think
most of the literature
4449.79 -> would suggest that for most people,
4452.44 -> 140/90 is a good number at
which we begin treatment,
4457.93 -> but make sure that is taken correctly.
4461.55 -> 'Cause if it's falsely elevated
4464.42 -> then way too many people will be treated.
4469.719 -> 150/90 is probably fine
for a lot of low risk,
4472.972 -> older, over age 60 people, not so old.
4478.75 -> But over age 60, to be between 140 and 150
4483.89 -> is not the end of things.
4485.3 -> It's fine if especially if
you're having side effects,
4488.19 -> don't wanna take a third
medicine say or whatever,
4491.34 -> that may be fine for a lot of people,
4492.94 -> especially if your overall risk is low
4496.08 -> or whatever your personal preferences are
4498.46 -> given that gray box diagram that I showed
4501.43 -> that you may not be the one who benefits.
4503.89 -> And for those who are very high risk,
4506.12 -> especially those with bad heart disease
4508.52 -> treating less than 130/80 may make sense.
4512.94 -> If you're in that situation,
4514.16 -> you're probably seeing a
cardiologist already anyway,
4516.95 -> and it will be their preference
to treat you to 130/80.
4520.49 -> And that's okay.
4522.37 -> 'Cause that's where the
evidence is strongest.
4526.63 -> And again, you shared decision making.
4529.59 -> What we mean by this is that
try to understand the numbers
4532.64 -> as well as you can.
4534.64 -> Health literacy is complicated,
4536.8 -> and this is what we call health numeracy,
4539.2 -> which is understanding the numbers,
4541.03 -> which is even more complicated.
4543.15 -> But if you're inclined that way
4545.02 -> and have a clinician who's willing
4546.32 -> to the numbers or point
you to a good website,
4549.46 -> then it's worth thinking about it.
4551.02 -> And you given the number needed to treat
4553.79 -> and the uncertainty here, I
think it would be incorrect
4557.2 -> for clinicians to be dogmatic.
4558.96 -> And so I think your preferences
about this rule the day.
4564.85 -> And what we've learned
particularly strongly off late
4568.19 -> is that using team approaches
are very effective.
4572.53 -> And some of the big systems
like Kaiser Northern California
4575.67 -> and others have done a terrific job
4578 -> controlling blood pressure
in their population
4580.74 -> with some innovative strategies
4582.44 -> that really rely on non-physicians
4585.53 -> particularly helping to
manage blood pressure,
4588.56 -> but it also includes careful measurements
4590.96 -> so that people aren't mislabeled.
4593.94 -> So with that I'll thank you and stop
4596.16 -> and leave plenty of time for questions.
4597.85 -> Thank you very much.
4598.738 -> (audience clapping)
4601.93 -> Yes, the question is where does stroke
4604.74 -> and atrial fibrillation come in?
4607 -> Well, the easiest thing to say is that
4609.57 -> in the causative relationship,
4612.48 -> high blood pressure is a risk
factor for producing both.
4617.13 -> So we definitely know that
4618.97 -> people with hypertension
and elevated blood pressure
4621.01 -> are a greater risk for stroke
4622.77 -> and also greater risk
for atrial fibrillation.
4628.19 -> Atrial fibrillation, the medicines we use
4631.4 -> to control atrial fibrillation
often do double duty
4635.84 -> as blood pressure pills.
4637.47 -> So some of the calcium channel
blockers, beta blockers,
4639.93 -> things like that.
4641.69 -> And so it's not in clinical practice.
4644.81 -> It's usually not that big a conversation
4647 -> 'cause you already need those medicines
4648.96 -> to control your heart rate
4651.22 -> since that's one of the ways they work.
4653.84 -> But for stroke, we do
recommend tighter control,
4658.28 -> but 140 is probably fine,
you don't have to go to 130,
4662.6 -> 'cause there is a little
bit of risk of being too low
4665.82 -> for some of these diseases as well.
4667.55 -> And so 140's probably the right way to go
4671.59 -> for both atrial fibrillation and stroke.
4674.44 -> And very importantly,
4676.38 -> although this is more
your clinicians issue,
4680.89 -> is when you're in the
hospital with a stroke,
4683.61 -> we let the blood pressure ride very high.
4686.48 -> And we've learned that
treating it too soon
4689.01 -> can be quite dangerous.
4690.22 -> So that's a little counterintuitive,
4692.82 -> but if you wander the halls
4694.61 -> of the neuro intensive care unit here,
4696.27 -> you'll see people with blood pressures
4698.3 -> routinely over 180, 190 and so forth.
4701.53 -> That's just when they're in the hospital
4702.88 -> during the acute stroke.
4704.37 -> As they come out over the
course of four to six weeks
4707.1 -> or whatever,
4707.933 -> then we begin to begin to treat it
4710.6 -> with a goal of getting
less than 140 for sure
4713.14 -> If they have concurrent heart disease,
4714.54 -> then we go to 130.
4716.26 -> So the question was in the grid
4720.88 -> with the number needed to treat.
4723.06 -> The harms were low
blood pressure, syncope,
4728.41 -> blood tests, abnormalities,
and kidney abnormalities.
4732.91 -> So they were all pre-designed side effects
4738.38 -> that were thought serious enough
4740.25 -> to send the patients to the
hospital to be evaluated.
4744.38 -> But so they're serious,
4745.98 -> but they're not like having a heart attack
4748.73 -> or a stroke or dying, you know?
4750.1 -> So that's when I say they're serious,
4751.73 -> but not as serious as the benefits.
4754.323 -> (indistinct)
4755.51 -> Yes, there are medicines that
can cause high blood pressure,
4760.15 -> the most important are illegal ones.
4763.767 -> (audience laughing)
Yeah.
4764.6 -> So methamphetamine and cocaine
are two on the short list,
4770.33 -> some of the other
derivatives in that category,
4772.88 -> such as a pseudoephedrine
that people take sometimes
4776.49 -> for respiratory congestion, phentermine,
4779.87 -> which is a weight loss
drug that I don't recommend
4782.5 -> can raise your blood pressure.
4784.14 -> And there are a handful of others.
4786.22 -> Well, that depends.
4787.16 -> So the comment was
about prostate medicine.
4789.64 -> The most common prostate medicine
4791.94 -> actually lowers your blood pressure.
4793.95 -> It's a class of medicines,
4796.38 -> in fact that we used to use
to treat high blood pressure.
4799.78 -> So that would be an unusual circumstance,
4803.04 -> But yeah, let's see, sir.
4806.71 -> Is very low blood pressure a risk factor.
4809.113 -> - [Man] And at what level?
4810.504 -> - Yeah, that's controversial.
4816.68 -> If you were gonna draw the relationship
4819.72 -> between ill health and
blood pressure on a curve,
4824.92 -> the shape of the curve is so
4827.65 -> ill health would be on the Y axis,
4830.18 -> your blood pressure's on the X axis.
4832.79 -> The shape of the curve
in many studies is a J,
4837.98 -> that is to say that the
lowest blood pressures
4842.42 -> are associated with poor outcomes.
4846.49 -> Now that's a little bit confusing
4848.42 -> because some of the people
4849.62 -> in those kinds of studies are sick.
4852.09 -> And so if you're frail
and at the end of life
4854.48 -> and your blood pressure's coming down,
4856.55 -> that may account for some of that J.
4859.47 -> But the current concern is
that it also may increase
4864.08 -> the risk of heart attacks,
4865.88 -> that you need a certain blood pressure
4868.51 -> to fill the vessels that supply the heart
4872.51 -> when the heart is relaxing,
so called diastole.
4876.513 -> And so there is a concern
about that, is not proven.
4881.23 -> The studies have yoyod a little bit
4883.4 -> over the course of the
last several decades,
4886.91 -> but it is a concern that over-treatment,
4891.67 -> or at least in Denovo,
4893.57 -> without treatment people
with lower blood pressures
4897.75 -> may well be at increased risk.
4899.41 -> And in the treatment studies,
4900.95 -> if you treat too low,
4903.26 -> there may be an increased
risk of heart attack
4905.46 -> and at risk patients.
4907.19 -> And so that is one of the concerns.
4909.5 -> And that's why you saw that
people were passing out
4914.36 -> with the aggressive treatment.
4915.93 -> They weren't having more
heart attacks though
4917.61 -> in that study.
4919.23 -> So the literature is mostly reassuring,
4922.57 -> but there has been a concern circulating
4924.86 -> in the scientific community
that may be too low,
4928.29 -> can increase the risk of heart attacks.
4930.17 -> But in many heart conditions
like heart failure,
4935.41 -> we treat people very low and
that's for a different reason,
4939.51 -> that's to allow the heart
to function, to pump better.
4943.23 -> So that's a different conversation.
4945.02 -> So there are different circumstances
4946.72 -> where we would strategically aim for low.
4951.37 -> But for specifically a
coronary artery disease,
4954.22 -> there's this concern.
4955.57 -> But again, the SPRINT Study
was reassuring in that regard,
4958.56 -> there was no increased
risk of heart attack
4960.89 -> in the low group.
4962.47 -> In fact, they had less heart attacks.
4964.68 -> So the current thinking is probably okay,
4968.27 -> and especially if it's your second number,
4969.97 -> that's really low.
4971.14 -> So sometimes especially
as people get older,
4974.83 -> the blood vessels get stiff.
4976.39 -> And so the upper number may be high
4978.967 -> and you have systolic high blood pressure,
4981.92 -> but the lower number is
really low, like 60 or 40,
4985.32 -> or maybe it just keeps, it never goes,
4987.38 -> you know, you can't record any number.
4990.09 -> And that's okay.
4991.53 -> As far as we think that that's okay,
4993.87 -> that's not associated
with increased risks.
4995.78 -> But it has been in the
literature as a concern.
4998.78 -> But the current thinking is
it's probably not a problem.
5002.38 -> So the question is, is there any evidence
5004.32 -> about which class of drugs is better
5005.81 -> for any specific patient?
5007.8 -> And if you go back in the history
5011.46 -> of the Joint National
Commission Recommendations
5013.63 -> over the years, there's
been a wide variety...
5017.51 -> There was several iterations
where thiazides were best
5021.05 -> for everyone.
5022.13 -> So I used to tell the residents,
5023.8 -> everyone should be started on a thiazide.
5026 -> And then the literature
changed a little bit
5028.19 -> and it became thiazides or beta blockers.
5030.89 -> So then I would say to the residents,
5032.24 -> well, thiazides should be first or second.
5036.07 -> You could start with beta blockers
5037.35 -> you could start with thiazides.
5038.58 -> Now we have three other drugs.
5041.61 -> So now we say, thiazides
need to be in the top three.
5045.7 -> So the recommendations have changed.
5049.83 -> As you notice, beta
blockers are off the list
5052.68 -> because we think they don't
work as well to prevent stroke.
5055.6 -> The prostate medicines are off the list
5057.79 -> because they're inferior to other classes
5059.94 -> of blood pressure pills.
5062.563 -> And in African Americans
there's monotherapy,
5067.85 -> the ACE inhibitors and
ARBs don't work as well.
5070.5 -> But the other studies...
5071.8 -> There is a literature out
there of monotherapy, you know,
5074.36 -> which drug is better at the start,
5075.94 -> but that's sort of a silly question
5078.94 -> because most people end
up as they age anyway,
5082.92 -> and needing more than one drug.
5085 -> And so it doesn't really
matter what you start with,
5087.84 -> 'cause everything works.
5089.88 -> And it's really more about
side effect, profile costs,
5092.64 -> formulary preferences, and so on.
5095.33 -> So if thiazide makes you urinate
5098.62 -> and that's a problem for you,
5099.76 -> then that's not a good drug for you.
5101.16 -> And it doesn't matter whether
it's two millimeters better
5103.58 -> than the other one or not.
5105.58 -> Or if ACE inhibitors cause
your potassium to go too high,
5110.13 -> then that become a more dominant question
5112.43 -> than whether it's two
millimeters better or for worse
5115.3 -> But in general, the main thinking is that
5117.85 -> in African-American's,
5118.97 -> there is a class preference based on race.
5122.62 -> But if for everyone else
it's thought to be neutral
5124.74 -> and that's why you get the
smorgasbord of four classes.
5128.63 -> So there is a literature on that,
5130.25 -> but it's probably not
worth concerning about it
5132.747 -> and the guidelines have
ignored that literature,
5134.88 -> basically discounted it.
5136.1 -> So the question is, if
home measurement is low
5143.14 -> and your office measurement is high,
5144.99 -> is it a measurement error or
is it white coat hypertension?
5149.02 -> The answer is we don't know.
5151.41 -> And so what you wanna do
is either thoughtfully
5154.77 -> look at the cuff you purchased,
5156.31 -> or what I would recommend to a patient
5158.66 -> is to bring the cuff in
and we'll do it together
5162.76 -> and see what the story is.
5164.12 -> But sometimes the cuffs
are just too small.
5168.32 -> The single manometers in the office
5170.03 -> are maintained carefully.
5172.36 -> The digital measurements
that many of the offices use
5177.17 -> are as good as the
mercury sphygmomanometer,
5179.45 -> if they're maintained correctly.
5181.8 -> And the home measurement
tools can be as well,
5184.73 -> especially if it's a
standards sphygmomanometer.
5187.78 -> But, you know, things
need to be maintained,
5190.3 -> so a cuff that ages may
lose its accuracy and-
5194.47 -> - [Man] Quite brand new when it was.
5195.663 -> - Consumer reports does review these
5199.2 -> and I won't favor any one machine
over another, but they do.
5204.01 -> And so they're a good organization.
5206.84 -> I'd follow their recommendations.
5208.13 -> But I think the most valuable
thing is to bring the cuff
5211.41 -> into the physician's
office and just compare.
5214.2 -> And that way you'll get a
chance to see how you're doing.
5216.85 -> You know, if your
measurement technique is good
5219.08 -> and if the equipment is good.
5221.3 -> And on that note, I'll stop.
5222.77 -> I'll stay take some
additional questions upfront.
5225.54 -> Good evening, everyone.
5226.373 -> - Thank you.
(audience clapping)
5227.964 -> (upbeat music)
Source: https://www.youtube.com/watch?v=j314amPw4RQ