Hypertension Guidelines Versus Life Experiences

One of the advantages of practicing clinical medicine, and seeing patients daily for many years, is you develop your own long-term study regarding certain medical health issues. In the area of hypertension, I have been taught by the best since my internship with pioneers such as Eliseo Perez Stable and Barry Materson at the University of Miami affiliated hospitals, Jackson Memorial Program, ensuring that their trainees were up to the task.

The goals and guidelines have changed. Lifestyle changes including salt restriction (sodium chloride), weight reduction, smoking cessation, reducing alcohol intake and regular exercise will always be mainstays of non-pharmacologic treatments.  We used to be taught to keep the systolic blood pressure at less than 140 and the diastolic blood pressure at less than 85.  These numbers have changed over the years, having been lowered, with everyone over 120 systolic now being classified as having some degree of increased risk of cardiac, cerebrovascular or vascular disease and hypertension.

We originally were taught to start with a diuretic and keep raising the dosage until the blood pressure was controlled or the patient developed adverse effects. We learned that when we used one medication, pushing it to its limit inducing adverse effects along the way, patients just stopped taking their medications. This resulted in a change in strategy to using several medicines each with another pathway to controlling blood pressure but all at a lower dosage which did not produce any ill feeling adverse effects.  The downside of more medications was additional costs and more pills to remember to take.  As hypertension experts pushed us to lower systolic blood pressure to 120 or less in our geriatric population I was concerned that lowering the pressure that much would again create adverse effects which were as or more troublesome than the risk  of having a BP between 120 and 140 systolic.  An article in JAMA Internal Medicine looked at this issue. They looked at patients over 65 years of age who were hospitalized for non-cardiac related problems and whose blood pressure was over 120. They studied these patients at Veterans Administration hospitals over two year period. Patients with elevated blood pressure above 120 were given more medications and higher dosages to bring their pressure down to meet the more stringent guidelines. The result was that there were no fewer cardiac events than anticipated and no better blood pressure control at a year.  In addition, these patients suffered from an increased number of re-admissions to the hospital and “serious“ adverse events within 30 days.

The new guidelines for blood pressure control may be applicable in a younger healthier population.  In the geriatric population we may need to readjust our goals to account for the physiologic changes that occur in men and women who age in a healthy manner. More specific data on why there were more re-admissions and what serious adverse effects occurred needs to be made public to determine if the effort to tightly control blood pressure is to blame.

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.

I Lost 52 Pounds And Feel Fantastic!

Patients have noticed my recent 52 pound weight loss but, for the most part, have been reluctant to approach me to discuss it. I’m sure many have wondered if this was a planned weight loss or the result of a serious illness.

Let me bring clarity to any concerns. My weight loss was planned as part of a lifestyle improvement program and, as a result of my commitment, I now feel great!

Like many Americans, I had accumulated extra pounds due to poor food choices, large portions and poor health habits. Finally, I decided to get healthy BEFORE I became ill and my doctor insisted on it.  I established certain criteria in choosing a weight loss program. It had to be safe, effective and rapid. I did not want medications or injections to be involved. Any program I was to consider had to have a proven safety record with no patients becoming ill.  There needed to be a sane transition program and maintenance program to teach me how to prevent regaining the weight rapidly and how to move on and live a healthy future life.

After much research I found the Take Shape for Life Program (www.tsfl.com).  Clinical studies by Johns Hopkins, the National Institutes of Health (NIH) and other organizations have proven the effectiveness of this program.  It has been recommended by over 20,000 doctors.

Take Shape For Life provides a network of ongoing behavioral support, education and other tools while using the nutritionally-sound Medifast meal replacements.

TSFL participants eat six small meals per day – all of which are low in fat and sugar but rich in protein and nutrients.  The five daily small Medifast meal replacements are supplied by TSFL and are eaten every two to three hours along with one lean and green meal that you prepare yourself.  These small frequent meals keep you from becoming hungry and getting cravings. As part of the program you have access to a free health coach / guide / cheerleader who assists with recipes, lifestyle tips and helps order product. The low average monthly cost to participate in the TSFL program is about $315.

I started the program in mid January and reached my goal weight in just four months. I am now working on transitioning to the maintenance program. My lovely wife is also participating in the TSFL program and has over 40 pounds to date.

I suggest those of you who are struggling to lose weight discuss it with me.  The program is perfect for diabetics, hypertensives, individuals with heart disease and individuals with gluten sensitive enteropathy.

Please contact me with any questions you may have, to request information or, to begin your journey to achieving optimal health by enrolling in Take Shape For Life.

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.