Hypertension Guidelines for Elderly

Blood pressure (hypertension) recommendations have been swinging back and forth for a number of decades. It seems that the people in power at the time decide the level and some are not considering the age and individuality, but determine what they want only.

The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) jointly developed this guideline to present the evidence and provide clinical recommendations based on the benefits and harms of higher versus lower blood pressure targets for the treatment of hypertension in adults age 60 years or older. The target audience for this guideline includes all clinicians, and the target patient population includes all adults age 60 years or older with hypertension.

Going back in history, at first we said, don’t lower the blood pressure because you will decrease perfusion to vital organs and cause strokes, etc. Then it was “the lower the better” and that we should be aiming for presyncopal blood pressures. Then the ACCORD study came and 120 mm Hg was not clearly better than 135 mm Hg, so we said maybe “lower is not always better.” Then the SPRINT study came along and a BP of 120 mm Hg was better for CV events and death. Hence, the confusion and debate continues.

Since most diabetes patients do not die from diabetes but from cardiovascular disease causing strokes and heart attacks, we need to pay special attention in patients with diabetes.

This paper evaluated 21 studies of intensive blood pressure treatment. With treating BP to less than 150/90 mm Hg, nine trials had high-strength evidence that that there was a reduction in mortality, cardiac events, and stroke.

For BP less than or equal to 140/85 mm Hg, there were six studies that showed benefit with reductions in cardiac events and stroke, but a non-significant reduction in deaths.

What is the takeaway message from the two large studies, ACCORD and SPRINT? It could be that we should treat our patients gently and to avoid hypotension. Targeting below 150/90 mm Hg is clearly beneficial. Targeting below 140/85 mm Hg has benefits, but the law of diminishing returns kicks in at the lower end. The good news is that it is safe.

The studies did not emphasize the concept of measuring blood pressure outside the office to see if it is spiking out in the real world. This will help identify the white coat and masked hypertensive patients and may also tell us if medications are reducing blood pressures for the full 24 hours.

These are all important issues that could affect the outcomes of our hypertensive patients.

So there were 3 guidelines issued:

#1) ACP and AAFP recommend that clinicians initiate treatment in adults age 60 years or older with systolic blood pressure persistently at or above 150 mm Hg to achieve a target systolic blood pressure of less than 150 mm Hg to reduce the risk for mortality, stroke, and cardiac events. (Grade: strong recommendation, high-quality evidence). ACP and AAFP recommend that clinicians select the treatment goals for adults age 60 years or older based on a periodic discussion of the benefits and harms of specific blood pressure targets with the patient.

#2) ACP and AAFP recommend that clinicians consider initiating or intensifying pharmacologic treatment in adults age 60 years or older with a history of stroke or transient ischemic attack to achieve a target systolic blood pressure of less than 140 mm Hg to reduce the risk for recurrent stroke. (Grade: weak recommendation, moderate-quality evidence). ACP and AAFP recommend that clinicians select the treatment goals for adults age 60 years or older based on a periodic discussion of the benefits and harms of specific blood pressure targets with the patient.

#3) ACP and AAFP recommend that clinicians consider initiating or intensifying pharmacologic treatment in some adults age 60 years or older at high cardiovascular risk, based on individualized assessment, to achieve a target systolic blood pressure of less than 140 mm Hg to reduce the risk for stroke or cardiac events. (Grade: weak recommendation, low-quality evidence). ACP and AAFP recommend that clinicians select the treatment goals for adults aged 60 years or older based on a periodic discussion of the benefits and harms of specific blood pressure targets with the patient.

This guideline is based on a systematic review of published randomized, controlled trials for primary outcomes and observational studies for harms only.

People with Diabetes and HBP May Not Donate Kidneys

Yes, you read this right! The reason is most people with diabetes and high blood pressure (HBP) may have kidney damage that would not support living on one kidney.

Researchers are saying that donors with those conditions face a high risk of developing kidney problems themselves, and may need both kidneys in the long term. The advisory is part of a set of new metrics, based on a donor’s health prior to donation, that can predict the lifetime incidence of kidney failure or end-stage renal disease (ESRD).

Dr. Hassan Ibrahim, a nephrologist at the University of Minnesota Medical Center, led the team that looked at the health impacts from diabetes and high blood pressure, or hypertension, in living kidney donors. They found that people who have diabetes or high blood pressure have a two to four times higher chance of experiencing reduced kidney function compared to those who do not.

Dr. Darla Granger, director of the St. John Transplant Specialty Center in Michigan, and a transplant surgeon, said that people with diabetes are ruled out as donors at her facility. If a person has high blood pressure and wishes to donate a kidney, they may be considered on a case-by-case basis. Both conditions are top causes of kidney failure. “You don’t want to create end-stage renal disease in someone because you took their kidney,” she said. However, both hypertension and diabetes can be reversed with lifestyle and diet changes. Donors who can reform their lifestyles may be reconsidered, she said.

Both conditions, diabetes and high blood pressure are the top causes of kidney failure. Granger said, “If a person has high blood pressure and wishes to donate a kidney, they may be considered on a case-by-case basis. Obesity is affecting the donor kidney pool and type 2 diabetes is a disease related to obesity. ”

There are so many more people waiting for kidneys than there are available donors. People with diabetes or hypertension who want to help another person by donating a kidney may not realize that they could wind up hurting themselves in the long run. “You don’t want to create end-stage renal disease in someone because you took their kidney,” she said. “But both hypertension and diabetes can be reversed with lifestyle and diet changes. Donors who can reform their lifestyles may be reconsidered,” she said.

Sleep Apnea May Cause Blood Pressure Increase

I am finding some consistency in articles about sleep apnea and how it affects other diseases or conditions the patient may have. A new meta-analysis conducted by an international team of sleep and respiratory researchers suggests that untreated sleep apnea may be a major factor in causing medications to be less effective in reducing hypertension (high blood pressure) in some people.

In reading the entire article, there are several things mentioned that makes this meta-analysis more valuable. These include:

1. Using continuous positive airway pressure (CPAP) therapy may be a key to helping people with hard to treat hypertension.
2. Most people with resistant hypertension also have obstructive sleep apnea (OSA).
3. OSA and resistant hypertension is a deadly combination that exponentially increases the risk of death or disability from a stroke or heart attack.
4. The study indicated that the patients with resistant hypertension and the very highest blood pressure experienced the greatest reduction in blood pressure after using CPAP therapy
5. This response suggests that untreated sleep apnea may be why these people haven’t seen improvement in their blood pressure despite the concurrent use of three or four medications.

Ulysses Magalang, MD, the study’s principal investigator and director of the Sleep Disorders Center at The Ohio State University Wexner Medical Center and co-author Christopher Valentine, MD, a nephrologist at Ohio State’s Wexner Medical Center both say that these findings suggest that physicians may need to be more aggressive with screening for sleep apnea and ensuring CPAP therapy compliance in patients with resistant hypertension.

Dr. Valentine did say, “That there is evidence about the benefits of CPAP in people with hypertension and OSA, but ours is the first analysis to systematically review CPAP use in people with difficult to treat hypertension and apnea.” He continued, “The results are clinically relevant because the effects that we found are significantly higher than what’s been previously observed in a more general hypertensive population. CPAP use could offer this subset of patients a new chance to reach a healthier blood pressure goal, or even to reduce their medication burden.”

Drs. Magalang and Valentine say that their findings also support the idea that resistant hypertension and OSA represent an “extreme phenotype” of those who have OSA, but never develop hypertension. The researchers further suggest that resistant hypertension in those with sleep apnea may be caused by a less common gene variant that nonetheless has significant impact.

It’s a hypothesis that will likely be put to the test over the next decade. The researchers who collaborated on the paper all belong to the Sleep Apnea Genetics International Consortium (SAGIC), a partnership of scientists from five continents who are building the first-ever international biomedical database to uncover the genetic causes of sleep apnea. By collecting biological material from thousands of patients with sleep disorders, the group hopes to amass enough data to start identifying underlying genetic causes of different conditions.

“We’re only just now beginning to appreciate the link between sleep apnea and disease,” said Magalang. “We hope that one day we will find common genes shared between people who have uncontrollable blood pressure and sleep apnea, and that will open up a whole new world of interventions and treatment strategies.”

When Will Cardiologists Learn – Eliminate Wheat

I am happy that cardiologists are investigating alternative ways to lower blood pressure, but most are not considering the elimination of modern wheat from their patient's food. The good thing, and a big step in the right direction, is that they are investigating ways to help patients instead of automatically prescribing statins or other medications.

John Bisognano, M.D., PhD, and Kevin Woolf, M.D., a cardiology fellow at the University of Rochester Medical Center, conducted a comprehensive review of the evidence behind a wide range of non-prescription drug interventions for the treatment of high blood pressure. The review is featured in the September issue of the Journal of Clinical Hypertension.

One of the best statements made is this one – Quote Woolf said” “There is not enough data to recommend any of these alternative options on a routine basis, but on an individual basis he thinks they are useful. Patients have different backgrounds and different approaches to living their lives. This is where the art of medicine comes in; getting to know patients and what they will and will not embrace can help physicians identify different therapies that suit their patients' habits and that will hopefully make a difference for them." Unquote

If only more physicians would see this and do this to help their patients. If physicians got to know their patients and what they will or will not embrace, they just might learn how to become better physicians. While most cardiologists will not listen to the the ideas put forth by cardiologist Dr. William Davis, you should take time to read this blog (link now broken) and search his blogs for more information about high blood pressure, cholesterol, and blood glucose.

Dr. Davis has had some wonderful results in his efforts to reduce these and most revolve around the elimination of modern wheat from our diets. Dr. Davis has many blogs about wheat and what it does to our bodies. His book “Wheat Belly” is an excellent book and you should read an excellent review in this blog by Tom Naughton.

Read this article for the supplements, herbal medicines and other ways reviewed to improve high blood pressure.

Why Are You Missing Work?

While I had not really thought about it this way, it does answer some questions I was asked by some employers recently, specifically the human resource departments. I attended because the speaker wanted someone with diabetes he could call on. We had prepared for the meeting, but were hit with a few questions that took all of us by surprise. There were four of us on a panel (representing different non-contagious diseases) to answer questions plus the speaker.

This article goes a long way to answer one of the questions and another blogger did a good blog that covered another question. One of the questions was how liberal an employer should be in allowing absences by people with chronic diseases. Most of us had covered absences for doctor visits and other possible related absences. None of us was ready for one question. What about the times when an employee is unable to work a full day, but has no doctor appointment.

We all fumbled with this one. I mentioned depression as one possibility and hypoglycemia as another, but did not realize how much time was being lost. So this survey results article has been sent to the speaker to forward to the employers in attendance.

This survey was recorded from four countries – U.S., UK, Germany, and France and involved 1404 people with Type 1 and Type 2 diabetes that had reported a hypoglycemic event in the preceding month.

The average loss of workplace productivity on a per person, per month basis from a night-time hypoglycemic event was 14.7 missed hours of work or estimated dollar value of $2,294 per person, per year. It is noteworthy that 22.7 percent arrived late or missed a full day and events occurring during work hours showed 18.3 percent needing to leave work early or miss a full day.

Another piece of information also forwarded to the speaker and then to the employers is this from Diabetes Care via a BD Newsletter. This covers work loss and employees leaving work because of disability after age 55. Rather shocking and large numbers.  I had been alerted to this a few days ago by a fellow blogger.

The one recommendation the entire panel agreed should be considered by every employer was having a health screening at least annually for all employees. This would be a preventive measure and could be conducted during the workday and might help catch health issues before they became serious and then with follow-up would encourage people to take the steps to maintain good health. Emphasis was on stopping obesity, hypertension, diabetes, and related health issues.

These studies and the growing numbers of new diabetes every year is creating concern for employers. Some employers are taking positive actions and some are not handling the situation.