I recently read a discussion by 3 hypertension specialists, Drs. Jan Basile, Dominic Sica and David Kountz, on how to treat “resistant hypertension.” Resistant hypertension is blood pressure that remains above goal despite treatment with 3 drugs, from different classes, one of which must be a diuretic. 10-15% of patients with high blood pressure will have resistant hypertension. These are the people who always seem to have blood pressure at levels that are concerning despite using medications that should be working. We wonder if they are actually taking the medications, but they assure us they are. It's almost like they are just taking sugar pills.
Often patients such as these have extensive testing to see why their blood pressures are so high. They get put on even more medications which then have side effects, and eventually we may just give up and decide that they are as good as they are going to get. Giving up helps to avoid still more medication side effects, but patients with resistant hypertension continue to have significantly increased risk of strokes, heart attacks and kidney failure, which presumably could be reduced by controlling their blood pressure.
So what do the experts do first? They take the blood pressure right. Their scrupulous method of checking the blood pressure is to have the patient abstain from caffeine or excitement for 30 minutes prior to having the blood pressure measured. They then sit in the exam room quietly for 5 minutes and the blood pressure is taken automatically 3 times, at 1 minute intervals, and the results are averaged. Adequately measuring blood pressure in the clinic setting requires that the patient be sitting, back supported, feet on the ground, not talking.
This is almost NEVER the way we do it. Five minutes sitting quietly? When does that ever happen? This would mean just sitting, not messing around with a phone watching cute animal videos, not reading about which movie stars are splitting up, not yelling at one's kids who are wandering around the examining room trying to stick forks in the electric sockets.
As far as I can picture this, the only way to actually get a person to sit quietly for 5 minutes, unless they already know how to meditate, is to teach them to meditate. The easiest instruction is to count each breath up to 10 and repeat. When thoughts happen, which they inevitably do, the patient is instructed to notice them and go on with counting. Mindfulness based stress reduction, which was just demonstrated in an article in the Journal of the American Medical Association to be effective in treating insomnia in the elderly, also includes muscle relaxation and instruction on acceptance of emotions and sensations. But breath counting is a very basic meditation technique and can be taught in about 30 seconds. The nurse could do it, then go away for 5 minutes, come back and take the blood pressure. In silence. And then the patient has meditated, possibly for the first time ever.
So then you have taken the blood pressure correctly, and it is probably lower than it would have been with our standard techniques. This will likely reduce the number and dose level of medications patients have to take, and they have learned to meditate. They can do it again. It will help them sleep. Perhaps they will learn to like it, do it regularly, and it will reduce their levels of inflammatory cytokines. Then they will have fewer heart attacks.
I can hear the grumpy voices already saying that patients will never do this. I kind of think they will, though, if we advertise it properly. It is the ONLY way to get an accurate blood pressure, which will undoubtedly be lower than if we take the blood pressure the standard way. It will require a little bit of work flow rearrangement, but it is a great idea. I think I will try it first with patients who have resistant hypertension or those who I am thinking about putting on blood pressure medications for the first time. These are the situations in which both the patient and staff will be most motivated to try something new. I will also not necessarily tell them that they are meditating.
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.
Blog | Tuesday, May 12, 2015