Physician help make sense of latest blood pressure control findings

AMA Wire
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Three experts in hypertension control and treatment last week joined the AMA in a discussion that covered the results of the SPRINT trial, self-measured blood pressure monitoring (SMBP) and much more. Find out what they had to say and check out the resources they had to offer.

The SPRINT trial made a big splash in the world of blood pressure control last year, and with the recent USPSTF recommendation to use out of office blood pressure monitoring to diagnose hypertension following closely behind, many physicians are wondering how all of this information can fit into daily practice in ways that benefit their patients.

The moderator of the discussion was Michael Rakotz, the AMA’s director of chronic disease prevention. The three experts who joined Dr. Rakotz in discussion on the most pressing issues in blood pressure from 2015 were:

  • Harlan Krumholz, MD, a cardiologist, professor at Yale University, director of the Center for Outcomes Research and Evaluation at Yale-New Haven Hospital, and frequent contributor to the New York Times Well blog.
  • Janet S. Wright, MD, a cardiologist and executive director of the Million Hearts initiative.
  • Ray Townsend, MD, a nephrologist and director of the hypertension program at the Hospital of the University of Pennsylvania.

Here are three key takeaways from the discussion:

1.  The SPRINT trial results apply only to the specific group of patients who meet the study’s inclusion criteria

  • “There is a feature that I thought was very interesting,” Dr. Krumholz said. “You could get into this trial with a blood pressure as high as 180, yet when you looked at the blood pressure at baseline among the groups it was slightly below 140.”

    “You want to see to what extent [do the] inclusion criteria fit the people that I see in practice?” he added.

  • An article in the Journal of the American College of Cardiology, “Generalizability of SPRINT results to the U.S. adult population,” further investigates how many patients across the country might have been candidates for SPRINT. “The answer is 1 in 6,” Dr. Townsend said. “SPRINT was an important trial … but there [are] still a lot of patients out there, particularly younger ones, that don’t quite fit the inclusion criteria.”

2.  Is a lower blood pressure target better?

  • “In some cases,” Dr. Townsend said, “if you can safely and effectively—and with very little side effects—get someone down to around 120 on two or three drugs I’m all for it.”
  • Dr. Krumholz took a slightly different approach. “We’re in a position of needing to understand what the person’s point of view is,” he said. “We need to understand who you are—are you a person that hates taking meds or likes taking meds? There’s evidence that pushing you down … might be helpful, but it’s at some risk.”
  • Citing an article recently published in the Annals of Internal Medicine, “Let’s not SPRINT to judgement about new blood pressure goals,” Dr. Krumholz told the group, “It’s up to [physicians] to be honest and frame it in different ways for people to say there is a way to lower your risk, but most [patients] won’t be benefitted or harmed.”
  • “There’s a handful that will avoid certain complications,” he added, “but what we need are tools to be able to have these conversations and help us communicate this.”

3.  Three reasons you should use out of office blood pressure measurement
In light of the USPSTF recommendation for out of office blood pressure measuring to diagnose hypertension, the experts offered three benefits to having patients measure their own blood pressure through SMBP—measured over a longer period between office visits:

  • It confirms the diagnosis of hypertension, eliminating the white coat response that is often present in the office.
  • It is a better predictor of future cardiovascular events than in-office measuring alone.
  • A patient who is self-monitoring is more likely to own their blood pressure control. “Patient engagement is critical to good [blood pressure] control,” Dr. Wright said.

Drs. Krumholz, Townsend and Wright took their blood pressure discussion to the furthest depths, answering many of Dr. Rakotz’s questions. You can watch the full discussion or visit the Google Hangout page for more information on blood pressure and blood pressure control.

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I believe the white coat response can be circumvented by having a nurse or other trained person in the office to take to BP, perhaps more than once. I believe the eating habits, including salt and soda drinks, plus alcohol all can add to an increase in BP. Family history is also present and a factor. BP is somewhat like an appetite which can be altered in many ways. Certainly hypertension is a disorder that is not to hard to diagnose in a few visits and these may have genetic factors as etiological basis. Thanks. GWR Retired 1999 after 40 yrs.
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Oct 25, 2016
A recent report calls for early-childhood and school-based policies and programs to accelerate the progress in helping kids achieve and maintain healthy weights.