Friday, January 31, 2014
Hypertension and the new Joint National Committee 8 recommendations for treatment
Doctoring is a practice based in science, but at its best, attempts to treat whole complex humans to achieve goals such as health and happiness which have no good scientific definition. Good doctors practice outside of boxes, and our success or failure is scrutinized closely according to very subjective criteria by our patients and colleagues. It is nice, in this situation, to have aspects of our work be based on clearly measurable variables; blood pressure, for instance.
The concept of high blood pressure as a clinical diagnosis began to be accepted at the beginning of the last century, correlated with the invention of the blood pressure cuff. It turns out that the pressure of blood in the arteries, when elevated, can lead to heart attacks, strokes, aneurysms and kidney failure and can be an indication of other serious medical illnesses including tumors of the adrenal gland and pituitary as well as narrowing of the blood vessels to the kidneys. Controlling the blood pressure has been effective in reducing heart attack and stroke rates, historically.
Blood pressure elevations are usually related to genetic factors as well as obesity, high salt diet, excessive alcohol intake. Lifestyle changes to reduce salt intake and obesity and increase activity significantly reduce blood pressure. The first consistently tolerable blood pressure medicine was produced in the late 1950’s and that class of medications (thiazide diuretics) is still one of the most widely used and effective ones available.
There are many classifications of drugs that can lower blood pressure and the production of new ones has been a staple of the pharmaceutical industry for many years. Since blood pressure medications frequently have unpleasant side effects or don’t lower the blood pressure very effectively, it was easy to produce new drugs that promised superior blood pressure lowering effects or less side effects or a more convenient dosing schedule.
A pleasingly simple and mutually enjoyable office visit for a patient and primary care physician in my experience included measuring the blood pressure, finding it to be just a bit too high, going to the sample closet, finding an attractively packaged new blood pressure medication with the placebo effect still firmly attached to the brightly colored capsules, giving it to the patients with instructions to come back in two weeks to see how well it worked. Unfortunately the shiny new medications were ridiculously expensive and usually too new to have been extensively tested to determine if they actually worked to reduce the target issues, stuff like strokes, heart and kidney damage, as opposed to just lowering the blood pressure.
Guidelines emerged from organizations such as the National Heart Lung and Blood Institute (NHLBI) to address which medicines to use and what blood pressure was too high and which patients to treat. There has been abundant research on blood pressure control and outcomes in different populations, fueled by both drug companies which wanted to prove their new blockbusters to be effective and experts in the field who wanted to find out what actually worked. Committees have attempted to digest this research, some good and some suspect, and come up with recommendations to guide practice.
The Journal of the American Medical Association published the Joint National Committee’s eighth set of guidelines, 10 years after the last set of guidelines came out. Guidelines are taken quite seriously by physicians and now by the people who pay us, who often scrutinize our adherence to them as a basis for performance based pay. These guidelines were 5 years in the making, I read, and were scrupulously discussed, based only on randomized controlled trials, and were delightfully succinct. There were three editorials in the same issue, generally approving them, though admitting that there is room for debate and improvement.
Briefly, and it is possible to be brief with these recommendations, the new guidelines recommend:
1. Treat all patients over the age of 60 with lifestyle recommendations plus medications if their blood pressure is over 150 systolic or 90 diastolic, aiming for a blood pressure just below this goal. Previous guidelines recommended a goal of 140/90 in this group. Patients who feel fine and are on medications with blood pressure significantly below this goal may remain on the same medications.
2. Patients between the ages of 18 and 60, start treatment with lifestyle measures and medications if the blood pressure is over 140 systolic or 90 diastolic, with a goal blood pressure of under 140/90. This same recommendation is true for patients in this age group with diabetes or kidney disease (which increase the risks associated with hypertension.)
3. Use drugs in only 4 classes to start, including diuretics, angiotensin converting enzyme inhibitors or angiotensin receptor blockers or calcium channel blockers such as diltiazem and amlodipine. Beta blockers are absent from the list of recommended drugs because of one well done study which showed an increase in death for patients on beta blockers, primarily due to strokes. Drugs can be started singly or in combination. For African-Americans use only thiazides or calcium channel blockers unless they have significant kidney disease, in which case angiotensin active medications are probably effective. Be sure to use doses of these drugs that are adequate but not toxic (there is a nice table.)
4. For patients with blood pressure above the goal after starting initial therapy, add another of the drugs in one of the 4 classes, but do not combine angiotensin receptor blockers with angiotensin converting enzyme inhibitors. If blood pressure still is not controlled, drugs in another class may be added, though it is unclear from evidence that this will make a difference in outcome.
These recommendations are not meant to entirely squelch creativity and do not address control of blood pressure in patients who have established heart disease, who may take other medications that control issues other than just the blood pressure and may interact with blood pressure medications.
I am generally very happy with these new guidelines. The fact that blood pressure goals for patients over the age of 60 are looser will significantly reduce the burden of treatment for these people, and reduce the number of fruitless visits in which both patients and physicians feel like failures because a number refuses to climb as low as we would wish. The standardization of blood pressure goals for patients younger than this, returning to the historical 140/90 as a goal of treatment will also simplify things. The treatment of blood pressure with reduction of disabling strokes and heart attacks that has been associated with this is a major success of modern medicine and simplifying treatment will probably make both patients and physicians more motivated to do it right.
Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
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David Katz, MD
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Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
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Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
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Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.
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Other blogs of note:
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
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One of the most popular anonymous blogs written by an emergency room physician.