Blood Pressure Control Becoming Trickier & More Personalized

In the era of the COVID-19 Pandemic it’s difficult to find published research which does not deal with the Sars2-Coronavirus. There have been several articles recently about blood pressure that have been of interest. One study previously mentioned discussed the development of a polypill. This pill contained small amounts of four different classes of blood pressure medicine. The researchers noted that in the past physicians were taught to try one pill and keep increasing the dosage until the blood pressure was controlled. The unfortunate part was that as the dosage of the one pill was increased the appearance of adverse side effects took place and patients simply stopped taking their medicines.

The polypill controlled blood pressure better than a single pill and produced fewer adverse effects than a single pill at higher dosages. A separate study reviewed this week looked at the same question. Should we just keep increasing the dosage of a single medication until blood pressure is controlled or should we add a second medication that works by a different mechanism. This study agreed with the polypill study finding that adding a second pill at a lower dosage lowered blood pressure more than a single pill and compliance was better as well due to fewer adverse effects.

A recent publication in the Journal of the American College of Cardiology, published by Tara Chang MD, MS of Stanford University School of Medicine in California, added to the confusion by suggesting that there should be different blood pressure goals for prevention of different diseases. Individuals with heart attacks may do better with a higher diastolic blood pressure than individuals trying to prevent a stroke. Ideally BP would be kept at the 110-120 mm HG to protect the brain, but this range might be too low to protect against another heart attack. For those individuals with both coronary artery disease and cerebrovascular disease the decision on how low to go needs to be discussed with your primary care doctor and cardiologist.

This is clearly an evolving science with more data to come. Hopefully with more data and study it will be less confusing for patients and clinicians as well.

Quadrapill for Blood Pressure Control

At the beginning of each patient visit I make it a habit to meticulously review with each patient their list of medications, supplements, vitamins, herbs etc. I compare their list with the lists on notes sent to me from consulting specialty physicians and then I access the pharmacy prescribing data base whenever it is available.

I am always amazed by how many chemicals we put into our body for the sake of maintaining health. How patients maintain accurate medication lists and administer daily medications is something I am in awe of. In the best interest of their care, I am always looking for a way to reduce the number of medications taken and to simplify the process if possible.

Clearly researchers in Australia feel the same way. They realize that to control blood pressure, most seniors are taking low doses of 2-3 medications. In previous years we physicians prescribed one medication and pushed its dosage to the limit before adding a second medication to gain control of blood pressure. We soon realized that at the higher dosages, patients experienced adverse effects and just stopped taking their blood pressure lowering medications.

In an intriguing study, Australian researchers created a poly pill consisting of one quarter of the starting dosage of four medications. Irbesartan 37.5 mg, (angiotensin receptor blocker), amlodipine 1.25 mg (a calcium channel blocker), indapamide 0.625 mg (a thiazide diuretic) and bisoprolol 2.5 mg (a beta blocker) were put into one pill. Five hundred ninety-one patients at ten medical centers participated in the study. Their average age was 59 years with a fair mix of men and women. They were randomly selected and blinded from knowing whether they were receiving the Quadrapill or increasing dosages of one pill. If BP stayed up amlodipine was added.

At the end of three months the poly pill group had lowered their BP by 6.9mm Hg more than the single pill group. At a year the figure stools at 7.7. millimeters mercury. There were no significant adverse effects in the poly pill group. The study clearly showed that taking a pill with multiple types of blood pressure medication, at low dosage, controlled blood pressure and was convenient and tolerable. That pill is now in development and should be presented to the FDA and European Union for review in the near future. It’s release to the public will certainly make taking medication simpler and more convenient.

Deep Breathing to Lower Blood Pressure

A new breathing device called Resperate is being marketed to slow your breathing rate, stimulate your parasympathetic nervous system and ultimately lower your blood pressure. The device sells for $330 and has been discussed in numerous health letters the last few weeks including the Harvard Health Newsletter.

The sympathetic nervous system controls involuntary functions such as breathing, digestion, heart rate. The parasympathetic division of it can slow your heart rate, dilate blood vessels and ultimately lower your blood pressure. The Resperate device uses sensors on your chest connected to a belt device to create a slow melody for you to listen to and breathe to. You synchronize your breathing to the melody slowing your breathing with prolonged exhalations. The slow breathing stimulates your parasympathetic nervous system slowing your heart rate, dilating blood vessels and lowering your blood pressure.

The device is used four times per week for 10-15 minutes sessions and should lower your diastolic and systolic blood pressure over a few weeks. How much and for how long does the effect work is currently unknown.

Medicare does not yet cover the cost of the device but some private insurers do.  After reading about slow breathing lowering blood pressure I looked for information on breathing techniques to lower your blood pressure without requiring a breathing machine. A website viitalheartandbrain.com offered several options:

Thirty Second Method: Sit in a quiet place and relax. Set a timer for thirty seconds and begin. Take six slow deep breaths through your nose and exhale slowly through your mouth during the 30 second period. Repeat the process as often as you can. This method studied with 20,000 Japanese adults lowered BP.

Equal Breath Length Method: Begin by sitting or lying down in a quiet area and close your eyes. Inhale through your nose counting to 4. Pause and feel the air in your lungs. Exhale thorough your mouth to the count of four. Feel the emptiness of your lungs. Repeat as often as you can

4-7-8 Breathing Technique: Sit in a quiet place. Place the tip of your tongue behind your teeth. Inhale through your nose slowly counting to four. Hold this breath for a count of seven. Exhale through your mouth to a count of eight making a gentle whooshing sound. Repeat four times per session

Diaphragmatic Breathing: Lie flat on your back. Place a pillow under your neck and bend your knees up. Place one hand on your chest and one under your rib cage (diaphragm). Inhale slowly through your nose and watch the hand placed under your rib cage rise while the hand on your chest remains still. Exhale through your pursed lips while watching the hand under your rib cage descend and the hand on your chest remaining still. Repeat the process several times.

Give these relaxation techniques and slow breathing techniques an opportunity to relieve your stress and lower your BP and heart rate. In a previous post I discussed tea both green and regular tea lowering blood pressure. Try a cup after the breathing exercises for further relaxation. If tea isn’t your drink, then consider unsalted tomato juice, beet juice, prune juice, pomegranate juice or skim milk. These drinks all had a similar blood pressure lowering effect.

Aerobic Training Helps Blood Pressure Medications Do Their Job

We are always looking for ways to stay healthy with less medicine.  Miguel Ramirez-Jiminez, PhD of the  University of Castilla-La Mancha, Toledo, Spain presented a paper to the American College of Sports Medicine recently week and addressed this topic.

His group looked at 36 obese and overweight adults who normally did less than 120-minutes of physical activity per week. Ages ranged from 53 – 65 years with 22% postmenopausal women. They had all been taking blood pressure medications for at least eight years and all met the criteria for having the metabolic syndrome which includes hypertension, elevated blood glucose, elevated triglycerides and a large waist.

The group was randomly divided into a placebo group whose medication was stopped or a trial group who continued their antihypertensive medications for the next three days. All participants then underwent 24-hour ambulatory blood pressure monitoring. All the participants were then entered into a four-month cycling program three times a week. 

After completing the four months of cycling training the placebo group again did not receive their medications for three days while the trial group did.  Twenty-four-hour ambulatory blood pressure was then checked in both groups.

The group exercising plus taking their medications saw an average drop in blood pressure of 3-5 mm Hg in addition to the 5mm Hg noted just from the medication’s pre-exercise training. When the exercise program stopped, the extra drop in blood pressure additionally dropped. There is a phenomenon known as “post exercise hypotension” that can reduce your blood pressure for up to 24 hours after training. This is the reason experts advise 3-5 exercise sessions per week.  

The study also revealed that if you exercise aggressively, and hope to permanently stop your blood pressure medications, your pressure usually rises above acceptable levels.  Exercise is not a substitute for prescribed blood pressure medicines. The article can be found at www.medscape.com  

Tea Can Help Lower Your Blood Pressure

Researchers at the University of California, Irvine, led by George Abbott PhD and Kaitlyn Redford, published their findings in Cellular Physiology and Biochemistry explaining why and how tea lowers your blood pressure. They found that two flavonoid type compounds found in green and black tea activate a specific type of ion channel protein named KCNQ5 which allows potassium ions to diffuse out of cells to reduce cellular excitability. The two catechin type flavonoids acting on KCNQ5 in the smooth muscle of blood vessels relax these blood vessels.

Scientists have previously found that tea can reduce blood pressure by a small amount. Their discovery of the role of the KCNQ5 protein now gives pharmaceutical developers a target for future medications. Hypertension is present in one third of adults in the world.

Tea has been consumed for over 4,000 years and two billion cups a day are consumed worldwide. Next to water it is the most common liquid consumed on the planet. It all comes from the leaves of the evergreen species Camellia sinensis with a difference in the fermentation process producing either green, oolong or black teas.

In much of the world, tea is consumed with milk mixed in. Dr Abbott’s group found that in the laboratory when milk was added to the teas it negated the effects of the KCNQ5 protein. They additionally found different temperatures of the tea resulted in different effectiveness of the KCNQ5 protein. Professor Abbott noted however that in humans’ digestive tracts our stomach and intestines separate out the milk products from the active KCNQ5 protein allowing it to work. He also noted that with our body temperature being about 37 degrees centigrade, the positive effects of the tea continued to work independent of whether you consumed hot tea or iced tea.

The message from this research is that a cup or two of tea per day will help lower your blood pressure.

Taking BP Medications at Night More Efficacious Than in the Morning

The European Heart Journal published the Hygia Chronotherapy Trial which followed hypertensive patients in Spain for a decade between 2008 and 2018. There were 19,000 participants of whom 10,600 were men, all older than 18 and all being treated for high blood pressure.  The group was randomly selected to either take their blood pressure medications at bedtime or in the morning.  They were followed with frequent blood pressure checkups plus 48-hour ambulatory blood pressure monitoring to assess their sleep time blood pressures.

The study was performed only on Caucasian participants who went to sleep on what would be considered a normal day/night schedule.  The results were significant and important.

Those who took their blood pressure medications at bedtime saw the risk of dying from a heart or blood vessel related problem drop by two-thirds compared to those who took their meds in the morning.  Night time administration of blood pressure medications resulted in a 44% drop in heart attack risk, a 40% drop in the need for coronary artery revascularization, a 42% drop in the risk for heart failure and a 49% drop in stroke risk.  The overall reduction in risk for cardiovascular death was 45%.

This is a significant study which must now be performed in patients of color who tend to have higher night time blood pressures.  While these studies are in progress, it appears that taking your blood pressure medication before bed is the correct choice.

The Blood Pressure Guidelines Dilemma

The American College of Cardiology and American Heart Association recently published blood pressure control guidelines that suggest we should be treating blood pressure in 25 year olds the same way we treat it in 79 year olds and older patients. If you have any cardiovascular disease, or a 10% cardiovascular risk assessment over the next few years, they want your systolic blood pressure to be less than 130. They present excellent data explaining that as the blood pressure elevates above 130, the risk of a heart attack, stroke, vascular disease or kidney disease and, ultimately, death increase. No one is arguing these facts.

The American College of Physicians (ACP) along with the American Academy of Family Physicians (AAFP) recognizes this one size fits all in blood pressure control creates many problems. As we age, our arteries become less compliant or elastic. Stiffer arteries are more difficult to assess for blood pressure value. After we have exhausted the lifestyle changes of smoking cessation, weight loss, salt restriction and increased activity to control blood pressure; we are forced to use medications. We try to use low doses of medicines to avoid the adverse effects of the pills that the higher dosages can bring.

These medicines are costly. The more we prescribe the more patients don’t take them due to the cost. The more we prescribe, the more patients forget to take multiple pills on multiple schedules of administration. If we get the patients to take the medication we run into the problem of blood pressure precipitously dropping when patients change positions from supine to sitting to standing. If we are lucky, and the patient is well hydrated, then we may only be dealing with a brief dizzy spell. In other cases, we are left treating the consequences of a fall and injury from the fall. The more we strive to control your blood pressure to the new levels with medications the more we must consider drug interactions with prescription medicines being prescribed for other health problems seen in older Americans.

At this point, experts from the ACP Policy Board and noted hypertensive experts at the University of Chicago have suggested we follow the more liberal guidelines of the ACP individualizing our care based on the patient’s health issues. Personalizing care with individual goals makes sense to me, especially in my chronically ill patients battling blood pressure, weight control, age related orthopedic issues, and age related visual and urological issues plus other problems. We strive to do that in our practice allowing the time for discussion, questions and evaluation at each visit.

Ambulatory Blood Pressure Checkups versus Clinic Blood Pressures

General internists and family practitioners have very little equipment to use in diagnosing our patients other than a light, a reflex hammer, a stethoscope, an EKG machine, a spirometer (to test breathing) and a pulse oximeter. Some offices still have an x- ray suite today but that is less common in small independent practices.

The ambulatory blood pressure cuff is a device introduced as a way to test whether patients with office-based hypertension had an isolated anxiety elevation of their blood pressure because of the physician’s “white coat” or an ongoing problem that needed to be addressed. The monitor itself is a routine blood pressure cuff with a computer device and timed inflation and deflation mechanism. It was designed to take six blood pressure readings per hour while you were awake and four readings per hour during the night.

Patients are asked to bathe and groom themselves prior to arriving for an appointment and we then placed the cuff on their arm and activated the device. They returned it the next morning and we connected the recording chip to our computer. We received multiple readings per hour and the machine calculated average blood pressure readings, made graphs and answered the question of what type of blood pressure elevation we had seen in our office.

We have performed hundreds of these procedures on patients and it is extremely rare to see a report of a sustained or average elevation of the systolic or diastolic blood pressure in a range that requires the use of medication. We only use the ambulatory monitor on patients who took their blood pressures at home and said it was normal but always had a dramatic elevation while in the doctor’s office.

I was entirely surprised to read the article in Circulation which looked at employees of the State University of New York at Stony Brook and Columbia who had ambulatory blood pressures compared with “clinic” blood pressures. 893 individuals wore the ambulatory monitor and were compared to 942 who had clinic blood pressures taken. These were all young healthy individuals with none taking blood pressure treatments.

They found that the ambulatory monitor readings were higher (average 123/77) compared to clinic readings which averaged 116/ 75. The average BP was 10 mm higher in young healthy adults with a normal body mass index. This elevated ambulatory blood pressure was found to be most pronounced in young healthy individuals with the difference being less apparent with increasing age.

While the result was surprising it still supports the use of the machine in our older population of individuals who come in with a story of elevated blood pressures in the doctor’s office but normal blood pressures at home. We will continue to use the machine for just that purpose.

How Tightly Should We Control Blood Pressure in the Elderly?

A recent publication in a fine peer reviewed medical journal of the SPRINT study proved that lowering our blood pressure to the old target of 120/80 or less led to fewer heart attacks, strokes and kidney failure.  There was no question on what to do with younger people but to lower their blood pressure more aggressively to these levels. Debates arose in the medical community about the ability to lower it that much and would we be able to add enough medication and convince the patients to take it religiously or not to meet these stringent recommendations?

There was less clarity in the baby boomer elderly growing population of men and women who were healthy and over 75 years of age. The thought was that maybe we need to keep their blood pressure a bit higher because we need to continue to perfuse the brain cells of these aging patients.

A study performed in the west coast of the United States using actual brain autopsy material hinted that with aggressive lowering of the blood pressure, patients were exhibiting signs and symptoms of dementia but their ultimate brain biopsies did not support that clinical diagnosis. In fact the brain autopsies suggested that we were not getting enough oxygen and nutrient rich blood to the brain because of aggressive lowering of blood pressure.  Maintain blood pressure higher we were told using a systolic BP of 150 or lower as a target.

A recent study of blood pressure control in the elderly noted that when medications for hypertension were introduced or increased a significant percentage of treated patients experienced a fall within 15 days of the adjustment in blood pressure treatment.  This all served as an introduction to a national meeting on hypertension last week during which the results of this same SPRINT (Systolic Blood Pressure Intervention Trial) strongly came out in favor of intensive lowering of blood pressure to 120/70 to reduce heart attacks, strokes and mortality in the elderly and claimed even in the intensive treated group there were few increased risks.   On further questioning however by reclassifying  adverse events in the SPRINT trial to “ possibly or definitely related to intensive treatment, the risk of injurious falls was higher in the intensive vs conventional treatment group.”

What does this mean in the big picture to all of us?  The big picture remains confusing.  It is clear that lowering your blood pressure aggressively and intensively will reduce the number of heart attacks and strokes and kidney disease of a serious nature.  It is clear as well that any initiation or enhancing of your blood pressure regimen puts you at risk for a fall. You will need to stay especially well hydrated and change positions slowly during this immediate post change in therapy time period if you hope to avoid a fall.  Will more intensive control of your blood pressure at lower levels lead to signs and symptoms of dementia due to poor perfusion of your brain cells?  With the SPRINT study only running for three or more years it is probably too early to tell if the intensive therapy will lead to more cognitive dysfunction.

Blood Pressure Control in the Elderly Needs Common Sense and Individualization

The recent SPRINT study pointed out the benefits of lowering blood pressure to < 120 mm Hg rather than 140 mm Hg in patients’ high risk for cardiovascular events because this reduced all-cause mortality by 25% and cardiovascular events by 35%. The SPRINT study is ongoing and will hopefully one day answer the question of does this data apply to the older elderly or our increasing population of 80 and 90 year olds. Previous studies looking at presumed dementia including pathological autopsy review of brains hinted at aggressive blood pressure lowering causing low perfusion or blood supply to the brain resulting in dementia type symptoms. In lay terms the anatomic findings did not support the diagnosis of dementia but the behavior which was dementia like may have been due to over aggressive lowering of blood pressure preventing elderly brains from receiving enough blood.

Nanette Wenger MD, a professor Emeritus of Cardiology at the Emory University School of Medicine and one of the most common sense teachers of clinical medicine cited the need for individuality in treating this patient group. She reviewed the many existing blood pressure guidelines and suggested keeping the systolic blood pressure of people over 80 to < 150/90 while shooting for < 140/90 in younger adults. Her clinical talk at the American Heart Association meeting recently contrasted the treatment of an 80 year old active vibrant individual managing all his or her affairs , in contrast to a wheelchair bound mildly cognitively impaired person living in a skilled nursing facility. She talked about starting slow with a low dose of medication and gradually titrating the dosage to control the pressure while checking to see if the blood pressure abruptly drops upon standing up or sitting up from a supine position. In most cases it requires at least 2-3 medications at low dosage to control blood pressure without producing adverse effects. It is still unclear if both younger adults and certainly older adults will tolerate and take higher dosages and more medications to achieve the suggested outcomes that the SPRINT study is encouraging. This fact makes it increasingly clear that patients will need a physician who has the time and takes the time to learn of their lifestyle and how taking the medication impacts it. In today’s medical world of conveyor belt template driven care encouraged by employers and insurers, finding that type of individual attention and access is a challenge in itself.

“There really is no template for the oldest old,” Dr Wenger advised. For this reason geriatricians and primary care physicians who are accessible and take the time to determine the entire clinical picture are necessary to tailor individual care.