New Blood Pressure Treatments on the Horizon

Elevated blood pressure affects one in three adults worldwide but only 20% of those individuals have their blood pressure under control. Keith Ferdinand, MD, professor of clinical medicine at Tulane University School of Medicine, New Orleans, noted that effectively treating high blood pressure could prevent 76 million deaths, 120 million strokes, 79 million heart attacks and 17 million cases of heart failure over the next 25 years.

The reasons for poor blood pressure control include the cost of medicines, the need to remember to take multiple medicines to control blood pressure, lack of access to medical care with monitoring of blood pressure and many lifestyle issues including smoking, obesity, sedentary lifestyle.  One of the ongoing research studies designed to combat this public health situation is the development of the “polypill.”  To control blood pressure, physicians usually have to prescribe three different classes of blood pressure medicines. This involves purchasing three products and remembering to take them all at the appropriate times of the day.

However, the polypill puts several different types of antihypertensive medicines (three or four) into one pill that you take once a day. Ongoing research shows great success with this strategy. The question remains whether pharmaceutical manufacturers will now actually produce such a pill and sell it in the United States after the medication goes through the vigorous FDA approval process?

In a presentation at a recent American Heart Association conference, George Bakris, MD from the University of Chicago School of Medicine presented his results on the Kardia-1 study which involved injecting patients with a medication that inhibited angiotensinogen which begins the chemical process of raising our blood pressure. The study examined the effects of injecting various dosages of this medication and found that it not only controlled blood pressure well over 3-6 months but had few adverse effects. This injectable will require additional human studies before it is available and of course we have no idea what the actual price to patients will be. 

Despite this, the prospect of the polypill and an injectable that you can self-administer at home, and works for months at a time, is an exciting advancement in blood pressure control.

Heat Related Illness

It is summer time and the heat and humidity are higher than at any other time of the year.   We spend more time in the outdoors so we must learn to protect ourselves against the unique illnesses caused by this increased exposure.  Heat related illness occurs when your body cannot keep itself cool. As the air temperature rises, your body cools off by sweating.  Sweating occurs when liquid on your skin surface evaporates. On hot humid days, the evaporation of moisture is slowed down by the increased moisture in the air. When sweating cannot cool you down your body temperature rises and you may become ill.

Some people are at greater risk to develop heat related illness than others. This includes infants and young children, people 65 years of age or older, people with mental illness taking medications, the physically ill; especially those with heart disease, high blood pressure and lung disease.  Individuals who have suffered from heat exhaustion or heat stroke in the past have an increased risk of developing recurrent heat illnesses.

When your body overheats due to very hot weather and or exercise in the heat, you are susceptible to heat exhaustion. Patients experience heavy sweating, non-specific weakness and or confusion, dizziness, nausea, headache, rapid heartbeat and dark very concentrated urine.

If you experience these symptoms in the heat you need to get out of the heat quickly. Find an air conditioned building and rest in it. If you cannot find an air conditioned building then get into the shade and out of the sun. Start drinking cool liquids (avoid caffeine and alcohol which exacerbate fluid loss and heat related disease). Take a cool shower or bath or apply cool water to your skin. Remove any tight constricting clothing.  If you do not feel better within 30 minutes you must contact your physician or seek emergency help.

Untreated or inadequately treated heat exhaustion can progress to heatstroke. Heatstroke occurs when the internal body temperature rises to 104 degrees Fahrenheit or higher. Heatstroke is far more serious than heat exhaustion it can cause damage to your internal organs and brain and it can kill you.  Patients with heatstroke are running a fever of 104 degree F or higher. They complain of severe headaches with a dizzy or light headed feeling. Their skin is flushed or red in appearance and they are NOT sweating.  Many will be experiencing severe and painful muscle cramps accompanied by nausea and vomiting. Their heartbeats are rapid, their blood pressure low. They are often extremely agitated, anxious and disoriented with some experiencing tonic clinic epileptic type seizures.

Heatstroke is a medical emergency and you must call 911 immediately. While you are waiting for help to arrive remove their clothing after taking the patient to an air conditioned or shady place. Wet the skin with water and fan the skin if possible. If you have access to ice or ice packs place them on the patient’s neck, back, groin and armpits while waiting for help.

Heat illness is preventable. When the heat index is over 90 and you must go outside wear lightweight, light-colored, loose fitting clothing. Wear a hat or use an umbrella.  Apply sunscreen SPF 30 or greater 15-20 minutes BEFORE going outside. Drink plenty of water before you go out and 2-4 glasses of cool water each hour you are outside working in the heat. Avoid alcohol and caffeine including soda with caffeine.  Take frequent breaks every 20 minutes and drink water or sports drink even if you do not feel thirsty. Try to schedule your outside work for before 10 a.m. or after 6 p.m. to avoid peak sun exposure.

If you are being treated for chronic medical conditions ask your doctor how to prevent heat illness.  Patients taking antihistamines, some blood pressure medications (beta-blockers and vasoconstrictors), diet pills, anti depressants and antipsychotics impair your ability to control your internal body temperature. Water pills to prevent excessive fluid lead to dehydration. Anti-epilepsy and anti-seizure medicines impair your body’s ability to regulate internal temperatures as well.

Heat illness is preventable if you take the precautions outlined above.

Dark Chocolate: Cardiovascular Prevention

A study from Australia predicts that if 10,000 men with big bellies and the “metabolic syndrome” (abdominal obesity, diabetes, hyperlipidemia , hypertension)  ate 100 grams of  dark chocolate daily, it would prevent 70 non-fatal and 15 fatal heart attacks per year.  The total yearly cost of the chocolate is less than $50 per patient.   Recent studies have shown that dark chocolate can reduce high blood pressure and lower lipids.  This study was based on a model that predicted the effects of dark chocolate lasting for 10 years when, in fact, true research studies have not lasted that long.

This is a promising avenue of research involving a food substance that most of us enjoy.  For my patients, almost any food in moderation produces success.

The Turnovers are the Difference- Medical “Handoffs” Are Continually Fumbled

This is a humbling football season for those of us who root for Florida teams at the collegiate or professional level. It seems that each week after another loss we are listening to the head coach standing at the podium during a post-loss press conference talking about how if the handoffs had not been fumbled, and the ball dropped and lost, his team could have prevailed. It is hard enough to deal with the turnovers and fumbles when rooting for your team. It is far more difficult to deal with it when we are talking about human beings hospitalized and cared for by hospital employed physicians and then turned back to the community without communicating adequately, or at all, with the care team responsible for their continued care at the community level.

Take the case of GH, an 82 year old obese diabetic with high blood pressure, high cholesterol and heart irregularities requiring the use of Coumadin to prevent a stroke. He awoke one morning two weeks after a major auto fender bender and found his underwear stained in bright red and dark brown blood. His wife was unsure if it was coming from his rectum or penis so she called 911 and allowed the patient to be taken to the nearest emergency department.  He was seen by the emergency room staff and admitted to their contracted hospitalist service for presumed intestinal bleeding due to Coumadin toxicity.

Eight days later he was discharged home with an indwelling Foley catheter needed because of the “clots” in his bladder. His Coumadin had been stopped on admission and never restarted. GH could not get out of the bed and walk while in the hospital and he stubbornly refused to go to a nursing rehabilitation center as an interim step until he was strong enough to walk independently.  His frail 80 year old wife, battling a lymphoma herself, was given the task of caring for this obstinate man at home and emptying and caring for his indwelling urinary catheter.

On his first day back home, I received a phone call from his wife informing me of this. She didn’t know what she could possibly do to care for him because he weighed 230 lbs and he couldn’t get out of bed and walk. A nursing service and physical therapist had been requested but had not yet called to schedule a visit.  She was particularly disturbed because 12 hours had gone by since he got home with no urine appearing in the bladder drainage catheter. At the same time his lower abdomen was growing in size and he was feeling pain and discomfort at that spot.  Once again, 911 was called and he was taken back to the same emergency department. Paramedics transport sick patients to the geographically closest facility not necessarily the one his physician sees patients at.

GH was readmitted because his catheter was blocked with clots and needed irrigation and there were concerns about a urine infection. I spoke with the wife and children and asked for the name of his doctor but they could not remember it. They did remember the name of his consulting urologist. I called the urologist who was a bit put out to discuss the case with me. He told me that “our“ patient was bleeding from the urinary tract due to a transitional cell cancer of the bladder that he discovered and treated during a cystoscopy. He felt the prognosis was excellent.

The urologist declined to discuss whether the patient was additionally bleeding from his intestinal tract or if the appropriate evaluation had been done. He suggested I find the hospitalist responsible for the patient’s care. When I asked for the name of the hospitalist he told me he had no idea who it was. “They all look the same to me,” was his actual response.

I asked the patient’s wife to have her husband sign an authorization to release medical records and obtain the medical records of his admissions for my review. She did that and presented it to the medical records department who sent me a brief summary of his second admission. It took three phone calls to obtain the records of the first admission and another to get the emergency department records.  I needed this material because it was quite easy to convince the patient to come to a local rehab facility after this hospitalization with me as his attending physician.  The patient and family had no idea why he was bleeding other than “I had clots” in the bladder. They didn’t know the name of his hospitalist either.  When I received the records it identified the physician. I called the hospital to page her but was told she was “off “for the next few days. Her colleagues on duty did not know or remember the patient.

The patient records finally arrived. His admission diagnosis was bleeding due to Coumadin toxicity, but the INR (a measure of how effective the Coumadin is in thinning the blood) was very low indicating that his blood was not anticoagulated much at all.  An INR of 1.4 doesn’t cause bleeding and is not toxic. The medical record said he had hematochezia (blood in his stool) but there was no documentation that anyone had performed a rectal exam or examined a stool specimen for the presence of gross or microscopic blood.

There was a lab order to type and cross-match the patient for a blood transfusion but certainly no mention that a transfusion had actually occurred. There was a thorough procedure note from a gastroenterologist who looked in his stomach and colon several days after admission and found no source of bleeding. I called the gastroenterologist on the day I received the records but he was gone for the Thanksgiving weekend.  The records indicated the patient’s blood count showed hemoglobin of 9.3 on the day prior to discharge and 8.3 on the day of discharge but there was no mention of an investigation of why the blood count dropped and why he was released with a dropping blood count.  A chest x-ray report on his first admission showed a right lower lung infiltrate but there was no follow-up performed or reported.

The patient arrived at the local rehab facility on Thanksgiving morning. I saw him and performed a thorough history, review of his records and an exam.  He was no longer bleeding, with no black stools noted on my rectal exam and no microscopic blood on the stool occult blood slide test I performed at the bedside. His Foley catheter was draining clear non bloody urine and the patient looked pale but well.

It was really very easy to convince this patient to come to rehab to learn to walk again once I became aware of his hospitalization and condition.  After my initial exam I sat down with the charge nurse and we constructed a care plan for the next few weeks at the rehab facility and explained it to the patient. Then I told the patient he had bladder cancer with a good prognosis. He was completely unaware of that diagnosis until we had the conversation.  I called his wife and children separately and reviewed the diagnoses and care plans for follow-up.

GH entered the hospital on an emergency basis as an unknown. He was appropriately taken to the nearest receiving facility by the paramedics when he was found to be on a blood thinner and bleeding actively.  His inpatient hospital employed physicians prevented a catastrophe and did what was necessary to make sure one was not ongoing. They did little or nothing to insure the loose ends of his medical problems resulting in hospital admission were addressed or understood by the patient and family.  Little or no effort was made to insure continuity of care and appropriate follow-up.

Judging by the editorials in our peer reviewed medical journals, this has become the norm not the exception in our insurance company / employer driven health care system. The devil is in the details. Unless the loose ends are planned for , understood and addressed, patients like this will continue to be bounced back to the hospital as an “emergency”, unnecessarily spending money we do not have and do not need to waste.