Stage I hypertension

I am going to talk to you now about stage I hypertension and what is an indication for beginning drug therapy, all of this presumes that you have measured the blood pressure repeatedly over several months, that you have counseled the patient about life style issues, you have made sure they are not on oral contraceptives, that they are not taking 14 ibuprofen a day, that they are doing reasonably what they can in terms of their dietary salt and alcohol intake. If the patient has a blood pressure of greater than 140/90 for more than a month, and they have something wrong with their heart, kidney or brain, or they have diabetes, they ought to be on a pill. If they have this kind of a blood pressure over this period of time and despite life style counseling, you cannot eliminate their other cardiovascular risk, they ought to be on antihypertensive medication. Other cardiovascular risks we talked about earlier, hyperlipidemia, diabetes, smoking or bad family history. Those are people with stage I hypertension 140/90 or more sustained on multiple readings who ought to be on medicine. IF the patient is officially elderly, 65 and they have sustained elevation of their systolic blood pressure over 150, that is systolic hypertension on multiple readings over at least a month time, the day to show that treating their blood pressure significantly reduces their risk and the last category is very difficult, people with stage I hypertension, they have no other risk factors, they don’t have end organ disease, they have this slightly elevated blood pressure that is slightly into the hypertensive range, it is very difficult to know what to do with those patient’s. Two things are reasonable, it is reasonable to work with them for a year on exercise, losing weight, whatever it is you choose to do and some physicians will choose to treat those patient’s. My own recommendation to you is to talk about it in a straight forward manner with the patient, and get their preferences. Some of our patient’s don’t want to take pills under any circumstances, and under the circumstance, avoidance of medication is a reasonable choice. On the other hand, people are more inclined to take medications they are worried about their blood pressure and when offered the choice, will take the pills, and those people I suggest you ought to give the medication.

This slide deals with the issue of how low to go when you start treating somebody with high blood pressure, this is from a recent study in the Lancet which deals with that issue and the bottom line is somewhere around 135 to 140 and somewhere around 80 to 85 in terms of the diastolic. Get the blood pressure below 140 and get the diastolic somewhere between 80 and 85, that appears to be the place where risk of cardiovascular events is optimized. You will notice in these slides that reducing the systolic blood pressure to lower levels does not reduce the risk and lowering blood pressure to lower diastolic levels does not reduce the risk, whether or not the risk of a cardiovascular event goes up here, if you get the blood pressure too low is an issue we don’t have time to talk about, remember 135/85 approximately, that is your target.

If the patient is elderly, this may or may not be possible, it may well be when the patient stands up, they are dizzy, so you may have to compromise, but 140 is a reasonable target, or slightly below for an elderly patient. The pharmaceutical industry has provided us with maybe 300 medicines for high blood pressure, maybe 300, so this is every bit as daunting for you as prescribing oral contraceptives is for me. So I am going to try to distill this into something manageable, these are the categories of antihypertensive agents. Fortunately, you don’t have to know all of that. What this slide shows is that all of the classes of antihypertensive agents, diuretics, alpha blockers, beta blockers, calcium channel blockers, and ACE inhibitors all lower blood pressure at starting doses exactly the same amount, they re all equally effective. Quality of life, impact of these drugs on how the patient perceives their life. Bottom line of this slide, all the same. Patient’s on diuretics do not feel quality of life any worse than patient’s on alpha blockers or beta blockers or calcium channel blockers, so that’s point two. Point three is, the cost, and this is a major differentiator of the classes of antihypertensives, diuretics are down here at the bottom, generic hydrochlorothiazide, $8.00 a month to the patient and if you choose to give the patient what the drug reps are trying to sell you, then you can get the patient to spend $40.00 a month instead of $100.00 a year they will be spending $500.00 or $600.00 a year for the same degree of blood pressure lowering effect and the same impact on their quality of life, and the vast majority of the data that we have about the benefit of antihypertensives is in diuretics and beta blockers. All you need to know is about diuretics and beta blockers.

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