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.

SPRINT Study Supports More Aggressive Blood Pressure Targets

For several years now there has been a growing controversy over how low to lower blood pressure to reduce health risks. The most recent recommendations were to lower systolic BP to 140 or lower in men and women less than 60 years old, with a higher systolic blood pressure of 150 in those over 60 years older. There has been much recent concern that if we lower systolic blood pressure too much in senior citizens we fail to perfuse the brain with needed blood supply carrying oxygen and nutrients. The end result is a clinical appearance of dementia or cognitive impairment. Researchers recognize that to achieve a systolic blood pressure of less than 140 most patients need to take at least two blood pressure pills. There has been a great deal of difficulty convincing patients to consistently take those two blood pressure pills so the thought of adding a third medication to achieve a systolic BP of 120 or less is quite challenging.

To answer the question of how low to optimally lower blood pressure, the National Heart and Lung Institute instituted the SPRINT study looking at 9300 men and women over age 50 that had high blood pressure. One group was attempting to lower systolic blood pressure to 120 or less. The other to 140 or less. The study was scheduled to run through 2016 and conclude in 2017. The goal was to see if the lower blood pressure reduced the number of heart attacks and strokes. Last week the Federal government announced that the reduction in heart attacks and strokes in the aggressively treated group was so pronounced that they were stopping the study early. With the lower systolic BP the heart attack and stroke risk was reduced by nearly a third and the death risk by 25%. To achieve the desired systolic blood pressure of 120 or less required the daily use of three distinct blood pressure medications per patient.

In the process of cutting the study short to announce the results for the public’s benefit, the researchers were not able to answer the question of whether senior citizens would suffer more falls from getting dizzy with the lower pressure or if the lower pressure resulted in more cognitive impairment and dementia due to hypoperfusion of the brain. The only question they answered is that a lower target blood pressure will result in less death due to heart attacks and strokes. They did not address the issue of whether lower blood pressures would result in less chronic kidney disease either.

There are many academic researchers who hail the SPRINT study as cutting edge in further reducing cardiovascular injury and death. Other researchers are peeved at the failure to look at the effects on dizziness, falls, dementia like symptoms and kidney function with the lower blood pressure in our elderly population. As a practicing clinician I will look at each patient situation individually. I will suggest maximizing lifestyle issues such as smoking cessation, weight reduction, lipid control and sensible exercise before adding additional medications to lower blood pressure even more. We will recognize that many of you are already on two blood pressure medicines, an antiplatelet agent, a lipid lowering agent plus other medications before we add a third class of blood pressure medicine to get your systolic blood pressure even lower. With the side effect profile of most blood pressure medications including electrolyte imbalances, fatigue, effects on frequency of urination and sexual function, we must consider the individual pros and cons of further lowering BP by additional medication very carefully.

United States Preventive Care Can Be Better, Center for Disease Control Says

Ralph Coates, PhD of the Center for Disease Control (CDC) described in the June 15, 2012 issue of Morbidity and Mortality Weekly Report that by looking back at a U.S. study done between 2007-2010 called “Use of Selected Clinical Preventive Services among Adults,” health providers need to do a more comprehensive job of offering preventive services.

According to the report, only 47% of patients with documented heart and vascular disease were given a recommendation to use aspirin for prevention. They additionally found that only 44% had their blood pressure under control. When looking at cholesterol and lipid control only 33% of the men and 26% of the women were tested with a blood lipid test in the last five years.  Of those patients who did measure their lipid levels, only 32% of the men and women surveyed had their lipids under control. Among diabetics, 13% had poor sugar control with a HgbA1C > 9 (goal is 6-8).

The data indicate that at 37% of the visits, patients weren’t asked about their smoking or tobacco status.  When patients were asked, and answered that they were smoking, only 21% were given smoking cessation counseling and only 7.6 % were prescribed medications or a way to stop smoking.

Screening for cancer needs improvement as well. Twenty percent of women between the ages of 50-74 had not had a mammogram in over two years.  In the same age group, a third of the patients were not current on screening for colon and rectal cancer.

The data was collected prior to the passage of the controversial Affordable Care Act. When the data was analyzed and divided according to socioeconomic status, education level, and health insurance status; it was clear that the poorest and least educated had the fewest screenings. It is hoped that with passage of the new health care law, and new insight by health insurers that it is cheaper to prevent a disease than treat it, these numbers will improve.

There are several other factors that need to be looked at as well. Data is now being collected from electronic medical health records.

I ask my patients about tobacco status on every patient visit.  When I note that the patient is smoking in their electronic health record, there are three or four ways to document counseling has been offered. Only one of them triggers the audit data for the government to review. Our software instructors were unaware of that when they taught us to use the system.  How much of this study is the result of data collection error is unknown.  “Health care providers” – not just physicians, are now delivering health care.

Access to physicians and a shortage of primary care physicians exacerbate the problem. It takes time to extract this information, record it, and counsel the patient. Because PCPs are underpaid, they will continue to see patients in high volumes to cover their expenses, causing the use of comprehensive preventative questioning to remain low.

New Suggestions for Managing High Blood Pressure in Senior Citizens

The American College of Cardiology and the American Heart Association have issued the first suggestions specifically for the treatment of high blood pressure in patients 65 and older. In the past, most research studies excluded patients 65 or older so it was difficult to extrapolate suggestions for treating younger patients to older patients.  The Hypertension in the Very Elderly (HYVET) trial changed that. It showed that when we lower the blood pressure in patients 80 years and older there is a decrease in deaths from stroke, a decrease in heart failure deaths and, decrease in death from all causes.

The consensus panel made the following suggestions:

1.  The general targeted blood pressure is less than 140/90

2.  Patients with coronary artery disease, diabetes and chronic kidney disease should aim for a BP less than 130/80 mm Hg.

3.  Lifestyle changes should be encouraged to manage milder forms of hypertension. This includes increasing exercise, reducing salt intake, controlling weight, stopping smoking and limiting alcohol to 2 drinks or less per day.  If this doesn’t work then medication treatment is indicated

The group supported the use of the “step care medication choice program” with the introduction of a thiazide diuretic as the first step in blood pressure medication usage.  They then went on to describe the appropriate usage of two medications at once, the use of beta blockers in cardiac patients and the use of calcium channel blockers.

They also supported screening patients’ urine for the presence of protein which would indicate that kidney problems need evaluation.  The group further suggested that the diagnosis of high blood pressure be made based on at least 3 blood pressure readings performed at two or more office visits.

The suggestions were not the more formal evidence based guidelines we have become accustomed to. They were a compromise agreement of a panel of experts from two organizations.  They encouraged further studies of these suggestions in the elderly so that they can accumulate the data they need to make future, firm, evidence-based guidelines.

For the average patient, nothing should change dramatically. As physicians, we will need to identify patients with elevated blood pressure and convince many of the elderly that there are significant benefits to taking medication to control their hypertension. This has been exceptionally difficult in the healthy elderly who develop hypertension in their mid to late 70’s and do not want to deal with the cost or side effect profile of taking “another pill.” Improving their lifestyle will always be the first option to control the elevated blood pressure.  However, the use of medications was strongly supported to control the pressure in those who need additional treatment.