Drug therapy of stage I hypertension

If it’s your sense that the patient’s diet is very highly laden in salt, it is a reasonable thing to ask them to try to reduce their sodium intake to a reasonable level. This does not mean that you should ask the patient to eat cardboard three times a day, which is what heart failure diet tastes like, what we’re saying is no added salt, avoid things that have lots of salt in them, anything in a bag, anything in a can that doesn’t say no salt, prepared meats, salt at the table, those are things which the patient should be counseled to try to reduce if at all possible. There is some evidence that eating large quantities of foods and vegetables which are high in potassium is a way to lower blood pressure a bit, but it’s also a good thing because it’s a good cardiovascular healthy diet because it’s low in fat. Moderation of alcohol intake to no more than that which you personally drink per day is a reasonable thing to do,smoking can’t be a good thing and Matt talked about fat. That is lifestyle modification, very difficult to do, most doctor’s don’t like to do it, my own recommendation to you in our office is to have your nurse trained to do most of these things and refer your patient’s to them, or connect yourself with some sort of counseling center in which people can get cardiovascular lifestyle counseling.

After you do that, and you decide that your patient might need medicine for high blood pressure, I am going to suggest to you that you can do this, you can do the vast majority of drug therapy of stage I hypertension and I am going to show you why you might want to do it, and how you might want to do it. First, it’s important to know that medicines work. Here is the evidence, trials of low dose diuretics, that’s 12.5 or 25 mg of hydrochlorothiazide, and beta blockers demonstrate important substantial clinically significant decreases in strokes heart attacks, heart failure and dying from one of these things, there is no doubt about the data. Interestingly enough, the biggest benefit is in old people. We used to have this misguided notion that old people with stiff vessels with tiny holes in the middle of them needed high blood pressure to get the blood to their brain, that was a really stupid idea, that was just about as dumb as it gets. What the data shows is that people who are older, have the highest risk of all these things and because in fact, they have the highest risk of them, when we lower their blood pressures even modestly, the absolute reduction in their risk is much greater than the absolute reduction in their risk in somebody who is young and has elevated blood pressure. The message here is, don’t write it off just because the patient is old. That is the patient who you absolutely want to treat. Treatment of 90 middle aged people for five years presents one major cardiovascular event, but you only have to treat 30 elderly patient’s for five years to prevent that same event and the reason is, is because of the much higher absolute rate or risk in older folks, and this gives you some sense of cost effectiveness issues, five years total outpatient cost, doctor, laboratory, medicines to prevent one major event, about $100,000 if you are using a diuretic, and if you try to use something that the drug representative is pushing on you on a daily basis, it will cost a half million dollars, implications, obvious.

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