(logo whooshing) (melodic tune) (gentle music) – I'm gonna speak about one
of my favorite subjects, which is high blood pressure. And it's one of my favorite
subjects for many reasons. I'm a primary care general internist and it's by far and away, the most common thing
that family physicians and general internists and
other primary care clinicians do in primary care practices is, help patients with their blood pressure. In addition, when we
look at worldwide health, depending on which study you read, there's some evidence
that high blood pressure is the number one cause of
preventable deaths worldwide.

Others would argue tobacco is on that list or maybe diet is on that list, but certainly high blood pressure is on the very, very top of that list. If not first, then in the top three. In addition in the United States, we know that the rates of
heart disease and stroke have been declining,
particularly heart disease. And when we determine why that is, we know that a lot of
the progress has been from the way we treat
heart attacks and strokes in the intensive care unit, but over half of it is from
the way we work with prevention of heart attacks and strokes with the treatment of common
risk factors as we call them. And the three most important, again, are tobacco high blood cholesterol
and high blood pressure. And again, you could
debate amongst those three, which has had the most impact, but again, treatment of high blood pressure, control of high blood
pressure is on the short list.

Now having said all that, another thing we know is that if you look at population studies, having a lower blood pressure is healthier than having a high blood pressure. And in fact, that relationship starts at pretty low blood pressure levels. In other words, if your blood pressure
is even over 110, 120, your risk statistically of
having a heart attack or stroke begins to increase. but it's a very small amount
for any given patient. And despite that observational evidence, that epidemiologic evidence, we still have a tremendous
amount of controversy about at what level to
actually begin treating it. And if we're gonna treat
it, how to treat it. And so that's my plan for tonight, is to address some of
those larger questions, both big and small related to the management high blood pressure. And I'll do that by first telling you that I have no conflicts
related to the material or any of the medications or devices I'm gonna speak about tonight.

And this is my roadmap. This is what I hope to
cover for you tonight. I'm gonna begin with
something that's very basic, which is how do I know if
I have high blood pressure and the corollary to that is what is the best way to measure it? So we'll spend more time than
you expect on that subject, 'cause it turns out it's
really, really important. How can I lower my blood
pressure without medications? When do I need medications? At what threshold do we begin treatment? Is it 160, 150, 140, 130, 120, what's the right number? And then if you do need treatment
for high blood pressure, what medications are best? We'll touch on all of those issues and several others along the way.

Now, the other reason
why I chose this subject for this year is because (clearing throat) there's a tremendous amount of controversy about this subject in
the medical community. And I'll spend some time
discussing that with you, but as you know, clinicians
now make a lot of decisions in office practice,
(clearing throat) excuse me, based on clinical guidelines. And so many different groups of experts write guidelines based on their reading of the best evidence, published the guidelines. And we seek consensus. And in many things that
we do over the years, we've developed certain consensus around, say screening for colon cancer, or mammography between
the ages of 50 and 69, or not doing pap tests under age 21. These are things where we
as a community of experts have come together and almost all the
guidelines are consistent and aligned with each other.

But as you'll see in the
treatment of high blood pressure, we have guidelines that
are uniquely distinct from each other and have major impacts. So depending on how you read the evidence and or how, which guideline
you choose to follow, it really leads to big differences in whether you need medications,
and if so, how many? And so I'll try to touch
on all of those things. So let's talk with
measuring blood pressure, and this is a humbling topic to talk about because you can get your
blood pressure measured now in the supermarket and the
pharmacy and hair salons and buy equipment from Amazon or your local medical supply store, the MAs on medical assistance, so the nurses will check
it when you come in to see the doctor or the dentist.

And so there's a lot of numb… And you can of course check it at home. And so there's a tremendous amount of measurement of blood
pressure being done. And the take home message
here is that we are very poor at accurately measuring blood pressure. And I recently wrote a paper on this, and if you wanna read more
of the references there asking the question, which is how can we treat
blood pressure correctly if we're not measuring it correctly? And I would argue, we
don't measure it correctly in any of the settings in which we have the
opportunity to measure it.

So let me review that a little bit. It's also humbling to
talk about this because for any of you who are health
professionals, yourselves, or have family members or
who are health professionals, this is the almost the
first thing everyone learns. And yet despite that, we
do it quite imperfectly as a profession. Now this is confusing because there are three different ways, they'll actually be a fourth
that I'll mention as well, to measure blood pressure. And it has to do with the
setting in which we measure it. So the most common is you
go into someone's office, a doctor, a nurse practitioner, whomever, and they measure your blood pressure. So that's called office measurement and that's actually
been our gold standard. So when we look at studies of treatment of high blood pressure, almost all of them have
used office measurement as the gold standard.

But of course you can also
measure blood pressure at home. And if you do that, (clearing throat) if you include home measurement as part of someone's regimen, it turns out that the patients
end up using less medication, but they also have less
good blood pressure control. And so it's a little bit of a trade off 'cause you tend to get
lower numbers on average, when you measure at home,
and I'll say more about that.

And then the third option
is something we called an ambulatory monitor, and these have been around for decades, but they're very underutilized. And what they are as you would
wear a blood pressure cuff, you could wear it for 24 hours or 18 hours while you're awake, it can be programmed to automatically take your blood pressure no matter what activity you're doing. And it gives us an average
blood pressure done robotically, if you will, over the course
of 18 hours or 24 hours. And it turns out from
some recent evidence, these ambulatory monitors,
this 24 hour average, correlates to the best with
strokes and heart attacks.

And when I use that abbreviation CVD, I'm talking about cardiovascular disease, which includes heart attacks and strokes. Now we have these three
different categories of blood pressure, and it turns out they measure different things and they don't correlate all
that well with each other. Sometimes in medicine, if we
comparing diagnostic tests with each other, we compare them to a gold standard and we can describe the characteristics of the test, which patients they might miss, which patients they might over detect. The problem here is that we don't know which is the gold standard. So we can compare them to each other, but we don't really know
what is the objective truth. So what we end up with is
three different strategies for measuring blood pressure
that we have to interpret each one on its own. Now the medical community
has reached consensus on how to measure correctly. And the last time I counted from one of the official guidelines that I'll make reference to later, there were 19 different
elements that constituted an accurate blood pressure measurement.

Now I've summarized these into eight, but it includes all 19. I've just combined a few. But what I want you to
do as I go through these is think about the last time you had your blood pressure measured in the office and which of these were followed and which of these were not. And that's really the punchline. And we'll also get to
the second punchline, which is when you're measuring your own blood pressure at home, you should do the same things
that I'm about to describe that the clinician
should do in the office. And so again, think about
how you're measuring your blood pressure at home and which of these best
practices you're following. So one of the most important things is that you need to be
seated for five minutes before the blood pressure is taken. So in my office, what happens often the patients have trouble. They're late for the appointment. They're having trouble finding parking, there's traffic around the office.

They finally get in the parking spots are painted too tight. Finally, get it in, you
almost hit the posts. You rush upstairs, the elevator
stopping at every floor. You finally come in, there's still time to get
checked in by the nurse. And she sits you down
and she starts reviewing your chief complaint and starts
reviewing your medications. And while she does that, she's cranking up the blood pressure. (audience laughing) So there are about six things wrong with that particular scenario. And one of the most important
is to allow the body to equilibrate before the blood pressure is measured. While the measurement is done,
the back should be supported, and the feet on the ground. Now, even in my own office
where I see patients personally, I cannot do this because
I have an exam table.

And the way the exam table is positioned to the cuff on the wall, I don't… It's not an exam table,
it goes up and down. So my patients don't
have their back supported and don't have their feet on the ground, even in my own office. So you're not supposed to
take any caffeine exercise or smoking for 30 minutes. I'll say more about caffeine later. Caffeine is not associated with high blood pressure
chronically, but in the short term, if you drink a cup of coffee right now, it can increase the blood pressure. My personal favorite is no talking. So no talking by the
patient and no talking by the person who's
taking the blood pressure. So this is one, certainly that
these initial blood pressures were often done incorrectly.

There should be no
clothing under the cuff. Another common mistake. So often your blood
pressure is being taken in a public setting, the cuff is put on over your clothes. That's incorrect. The arms should be supported
at the level of your heart, the atrium, one of the
chambers of the heart. So usually on a table or
on the clinician's arm, but up in this relaxed position. And probably the most important of all, or one of the most important of this list is a correct cuff size. And so most of the blood
pressure cuffs you purchase, if you don't go out of your way to ask for a larger cuff will be too small. And that's true for because
of obesity and overweight.

That's true cause of excess skin folds. That may be true cause
of excess muscle mass. But in our society, in my practice, I hang up the large cuff,
I take out the other ones I set them aside, and I
never use them all day long. 'Cause the large cup
will fit almost everyone. And if the large cuff is too large, you do not get a falsely low value. The only thing that all of
these different factors do is give you a value that's too high. So basically what we're
doing is over diagnosing high blood pressure by
the incorrect measurement of blood pressure. And that's true in the office,
and that's true at home.

So again, that's a long list. It's a lot of time spent
on this simple subject, but I think it's on the very short list. One of the most important things we can do to improve the way we
manage high blood pressure. And as I implied, this
is also true at home. So remember all of these things, when you're checking
blood pressure at home, these are the best practices
that you should follow at home.

– [Man] Can you comment regards how tight to make the way cuffs? – Let's take your questions at the end for the editing purposes. But the question was how
tight to make the cuff. The cuff is automatically, it's marked where to the fit it around the arm. Uninflated it should be comfortable. And when you're inflated, it gets tight. and the tightness is derived by how many millimeters of
mercury you inflated to. So if your blood pressure, if I think your blood
pressure might be 180, then I need to go higher than
180 in order to come down to get that measurement correct.

And if I get up to 200, it's gonna hurt. If I think your blood pressure is 130, I might go up to 160 and that would feel on the comfortable side of tight. So the cuff itself just
comfortably around that. So it stays on the arm
by itself basically. and then the pressure is what
determines that feeling that, ooh, that hurts a little
or that's too tight. The other controversy is
what blood pressure to count. And what do you write in the chart, or what do you write on your log at home? Most of the guidelines
in the United States talk about doing repeated
measurements and averaging them. That's okay. It's a little hard to do
the arithmetic in your head. You know, you have to
be, slick with the…

Write down the value 'cause you'll forget. Write down the second
value than average the two that one can do that. In the office it gets a
little more complicated because the medical assistant or nurses taking a blood pressure or two then do I count his or hers and then my own and average those two, or they do it twice myself
and just average my two. So there's a lot of uncertainty
about the best practice. But it turns out, and I'll
show you this in a few slides. It turns out that the acceptable
way, and this is true. The Canadians do it this way. And in fact, most of the quality measures in the United States do it this way, is you can record the lowest value. So if you've taken it two or three times, you don't have to average,
but you record the lowest one. And our definition of blood
pressure control is determined using the lowest value. So many people make an
error on that as well.

Now all of these things can
lead to a dramatic increase in blood pressure, and
I'm talking dramatic. 30 points millimeters of mercury. On average people report about 20, but some people it can
be substantially higher. So if your blood pressure is high, one of the first things
to do is repeat it. And in fact, a study was just done that was published earlier this year. And it was a study from
20 different clinics in a city like ours. And the medical assistants were instructed on these 19 features that I just reviewed of taking the blood
pressure best practice.

And then they were instructed
with one other thing, which was, they were told if
the blood pressure is elevated over in this case, 140/90, take it again. And just by taking it a second time, the blood pressure was under 140/90, over a third of the time. So repeating the measurements routinely give you a lower measure measurement in part maybe because that resting is happening now a little bit, that's settling down that
we talked about and so on. So that's a very easy trick,
is just take it again, and you can record the
lower of the values. And as I talked about, this
is an ongoing controversy and different practices
do this differently, but I think when you
look at quality measures in the United States, including the ones we use
from the federal government that are called HEDIS Measures or like the Kaiser's do in
their population studies and so forth, the quality community accepts
the lowest measurement when two or three values have been taken.

But the guidelines still often talk about averaging multiple measurements. Now there's also something
that's not common. I call it research grade measurement. And the way this was done in
this one particular study, which I'll come back to
called the SPRINT Study, the Systolic Blood Pressure
Intervention Trial, they had the medical assistant
take the blood pressure akin to the way we would in the office, and then they would instruct the patient to go into a quiet room that
was with them dim lighting. They would have an automatic
machine, a robotic machine, to take the blood pressurement. They would sit for five minutes. They had three automated measurements with some pause in between. There was no human in the room. All the different 19 features
were being adhered to, and the blood pressures were averaged. And what was fascinating about this is that when they compared
the values they got in the dark room with the
automated measurement, it was 12 and a half points
lower than what the nurse got in their advanced high
blood pressure setting.

This is a place where people
were coming to see experts to participate in a big study. And even in that big study compared to the robotic dark room, the dark room was 12
and a half points lower. Keep that in the back of your mind, because you'll see this
study turns out to be one of the major studies
that has influenced some of the guidelines that
suggest we should treat people at much lower values. And so it's a little bit of a catch 22. If you're gonna use the
research grade measurement, which is 12 points lower, then treating at a lower
threshold may be okay. But if you're gonna measure it the way we normally measure it, then may be treating it
at the higher threshold is also okay. And you'll see where the
guidelines fall out in that regard.

But remember this robotic measurement. And what we may see in the future is that more people will move to this. It would be pretty easy to
do in a busy office setting. You just set up, you need an extra room and a robot, just an
automated machine basically and it's pretty easy to do, but it's not how it's currently done. (clearing throat) Now, the other issue that has
become part of common practice led by consumers and also device makers is to measure the blood
pressure outside the office. And there is a consensus about doing this. In fact, the U.S. Preventive
Services Task Force as early as 2015, so several years ago, as part of their official recommendations for blood pressure management, suggested that measurements
should be a pain outside the clinical setting, meaning outside of the physicians, nurse practitioners office,
before starting treatment.

This is not common practice. Most clinicians continue to treat based upon their own measurement, but it is interesting
because many of us follow the U.S. Preventive Services
Task Force guidelines for other things like cancer screening. But in this case, it hasn't really been fully integrated into a common practice. People use home measurement
for a variety of things, but it's not that common
to use it routinely as a second test, if you will,
before you begin treatment. However, in England, that's what they do. And so the blood pressure
has to be checked outside of the office before
the patient gets treated, especially with medications. All right, let me move next
to home measurement briefly. I've already said several
things about this, and it turns out this is
not well standardized. You all, if you're measuring
your blood pressure at home, you're all doing it in your
private time and space, and I have no idea how you're doing it.

I barely know how my medical
assistant is doing it, but I certainly don't
know how you're doing it. Although one good trick is to
bring your machine in with you when you see your clinician
and demonstrate to them how you are taking it, which gives you the
opportunity to also make sure the cuff size is correct, that
your technique is correct, the machine is a well
standardized machine, correlates with the office
measurement and so on.

So that's not a bad little trick if you wanna be a little bit more precise in your home measurement. It's also not fully evidence-based, and what I mean by that is
when patients are assigned blood pressure treatment
with home measurement and compared to blood pressure treatment without home measurement, and that's the only extra intervention, there's no benefit of home measurement. Now that's a little misleading because if you did a real comprehensive program of blood pressure control, that included pharmacy
involvement and home checks and frequent checks and combination pills and things like that,
and home measurement, that is part of an integrated
comprehensive plan, home measurement can be a useful tool.

But when it's been isolated, as the only extra thing that's done, it doesn't help that much. It's a little bit like
checking blood sugars in people who are on pills for diabetes, where, now I'm not talking
if you're taking insulin, then you must check your home blood sugar. But if you're just taking
pills, depending on the pills, many patients do not need to
check their home blood sugar, and it's not associated with
a very significant change in diabetes control. And this is analogous to that. Correct home monitoring requires all 19 of those other elements. So everything that I
suggested in the office you should do at home and therefore again, bringing your equipment in and
having the nurse or physician watch you take your blood pressure is a good way to make
sure that your own skills are up to best practices. And again, things like correct equipment is also extremely important. And that's complicated now 'cause there's so much new equipment. Many, many of the new devices
have not been well-validated. And so people are selling
all sorts of things on fingertips and wrists and so forth.

And many of those measurements
have not been validated in rigorous studies. And when they have been
studied in rigorous studies do not correlate particularly well with the measures that I'm discussing. The correct timing is interesting because as I mentioned with
the ambulatory monitor, it's around the clock. And so you could argue
that doing home measurement that mimics the ambulatory
monitor might make sense, and that's not a bad way to do it. So rather than checking it every day or every day twice a day, or whatever, you could argue, maybe I'll
check it five times a day, one day per month, akin to my using an ambulatory monitor, so getting a measurement
throughout the day, because the blood
pressure goes up and down in a diurnal rhythm over the
course of a 24-hour period.

It's highest in the morning
and it's lowest in the evening. So if you're checking your
blood pressure after dinner, especially after a glass
of wine, kids are asleep, everything's copacetic, you're gonna get a lower
blood pressure then, than if you check it when you
first wake up in the morning before you've taken your medications. So that's important to know. And so what our current guidelines are, you can do this all day, one day, every now and again model, but the standard
recommendations are to check it in the morning before
you take your medications and then before dinner, as a way to frame the higher and lower.

But I don't recommend. They're very, very few patients who need to do this every day. You get too much information,
you get too worried about it. It's not adding value, but it is something to do
occasionally and keep track of it. And again, share that
information with your clinician. Home measurements, as I mentioned, are lower than office measurements. And sometimes people talk
about having different normals, but the relationship is
not uniformly predictable. So I can say if your blood
pressure is 145 in the office, it's 135 at home. It could be, but it might not be. So it's not a fixed relationship. On average, it's lower, but
in any individual patient or any individual measurement, the correlation is a little
bit better than a coin flip, but not a ton better. It's about 60 or 70% correlation. And as I mentioned, when
you isolate home management as the only intervention, the evidence has shown little impact. All right, the final part of this section is to talk about ambulatory
blood pressure monitoring.

And again, this is a machine
you would normally pick it up from the cardiology suite or where you might get
an electrocardiogram or maybe an echocardiogram,
or certainly a Holter monitor. That's where these live. They're relatively inexpensive. Medicare will cover these, especially if the right
diagnosis is put down, the right diagnosis being
elevated blood pressure, 'cause you're using it to help decide whether someone has hypertension, which is the disease,
versus not hypertension. So Medicare will pay if you
use elevated blood pressure. And again, I already
described how it works, you can program it to
do anything you want, typically it's several times
an hour while you're awake.

And usually a few times at night, most people can sleep through this. Again, it's slower than the office, but the relationship is unsettled. But as I mentioned, the recent studies, including a very thorough review by the U.S. Preventive Services Task Force has suggested that it predicts amongst a population of people, who's gonna get into trouble
with cardiovascular disease than the other tools. That is to say it's makes
blood pressure measurement the most predictive risk factor
for heart disease and stroke compared to office measurement
or home measurement.

So it's available, it's safe. It's not that expensive, but
we use it quite infrequently in modern American medicine. And I think one of the things
I favor is using it a bit more because misdiagnosing someone
with high blood pressure usually means a lifetime of medications. 'Cause it's rare once people get diagnosed with high blood pressure
that they get undiagnosed with high blood pressure, that requires a little bit of courage on the patient's part
and the clinician's part. It also is the best
way to detect something that's been called
white coat hypertension. And this is that syndrome
where your blood pressure is high in the office
and low everywhere else. That does exist. It's more common in women than men. It's more common in young than old. It's more common in Caucasians
than African-Americans. So it does exist. It's most common in young Caucasian women. And when you see an elevated
blood pressure in the office as a young woman, which is very important
to diagnose correctly because of the impact it
can have on pregnancy, but it can also be over-diagnosed.

And that's a setting where
careful home measurements or an ambulatory monitor can
be particularly important. You can also use it to monitor treatment and for some other purposes. So in summary, this simple task that we do from the pharmacy to the hair salon, to your home, to my office,
to the cardiologist's office, turns out to be a little
bit more complicated than we thought. And from a clinician point of view, we talk about really
rethinking the office workflow. I think who's ever
taking the blood pressure it's good to repeat the measurement.

Whoever you're working
with should think about whether to take averages
or record the lowest value. Home measurements are good. We probably do it more than we need to, but less accurately than we need to. So if you're gonna do it and do it well, but maybe a little less often, and make sure you're
following best practices, particularly things like cuff
size breasts and so forth. And again, similarly,
the ambulatory monitor should be used more. Probably doesn't need to
be used in every patient or even every patient with
nuance and high blood pressure. But we certainly, whenever we
have a sort of a tiebreaker, and a patient doesn't wanna
be on meds, for example, and the clinicians thinking, eh, I mean, you should be on meds, perfect situation to
get another data point and get the average under the curve and the area under the curve
and use the ambulatory monitor.

All right, so I'm gonna move on. That's what I have to
say about measurement. I think that's the longest
section of the talk but I think probably the most
impactful of the way it would, if done correctly, change
how we as clinicians practice and how you manage your
own blood pressure at home. (clearing throat) I wanna speak briefly about
treating high blood pressure without medications. This is something I've been interested in since early in my career. As many of you know, I studied nutrition before
I came to medical school and I've looked for the interface between nutrition and internal
medicine and chronic illness for my entire career.

And one of the first studies
I ever participated in was a study that compared
what we call nonpharmacologic or non-drug therapy for high
blood pressure with drugs. That study, it was a great study. We had 300 patients that we recruited and we managed them very carefully. My job was to teach them how
to manage it without drugs. And at the end of a year of followup, the drugs won hands down. And in fact, the NIH had funded that study and they had funded about a
dozen others at the same time. And every single study
showed the same thing, the drugs outperform
non-drug treatment uniformly across the board. So medications are very effective for lowering blood pressure. We'll see more about that in a minute. And nonpharmacological therapy
is a relatively modest tool in your toolbox across all patients.

But for individual patients,
it can be the answer. And so in the study, we were looking at the
average blood pressure between 300 patients
or 150 on the non-drug and 150 on the drug, but for an individual patient, the things I'm about to talk about can be extremely effective
and can either slow the need to take medications or allow you to take one less medication, or in some cases completely, treat the blood pressure
without medication. So it's a very potent tool in the toolbox for a motivated patient, especially one who has certain
clinical characteristics.

Now, one of the most important or predictive characteristics is if you're overweight or obese. And so if your weight is high and you have high blood pressure, and there's a close correlation
of those two things, then weight loss is uniformly effective at lowering high blood pressure. So if a patient can lose 20 pounds and keep it off for a year or so, the blood pressure will go down a ton and it's worth at least
one or two different pills or classes of medications. The problem is that it's
really hard to lose 20 pounds and keep it off. But for the patient, who's at that point where you're ready to do that, then weight loss always works
at lowering blood pressure. And it's quite well sustained. Now, eventually as you gain weight, or even if you kept the
weight off as you age, you're at risk of the blood
pressure drifting upward again over time, but you can delay medication
for quite some time if you're effective at
treating high blood pressure with weight loss and
those that are overweight.

Alcohol can also raise blood pressure. You don't have to become a
teetotaler if this is the case, but if your blood pressure is high and you're a moderate
to heavy alcohol user, three, four, five drinks a day kinda class is the way some of
these studies were done, and can get down to one drink a day, the blood pressure can
come down quite nicely. Although the amount you'll see is smaller than with weight loss, but it's a real effect, but
there aren't that many patients who drink that much and are
willing to stop drinking just for a little bit of
blood pressure control. They'd rather take a medication
I think in many cases. Salt intake is something
I'll say more about, but we've recommended salt restriction or sodium restriction for
decades for high blood pressure. It's part of our public
health recommendations for a healthy diet, and the numbers are complicated and I won't review them
particularly, but in general, restricting sodium can
lower blood pressure very effectively, but
only in some patients.

And it's probably somewhere
about a third to a half. And so it's a very
effective tool for treatment of high blood pressure in some patients, but it's more controversial
about whether the whole society needs to lower our salt intake. In other words, 'cause a lot of patients with high blood pressure won't benefit from sodium restriction, but if you have high blood pressure and if you're on a high sodium intake, and if you're African
American in particular or older in particular, both of which are associated
with reduced clearance of sodium by the kidney.

So reduce handling of a
salt load, if you will, then sodium restriction
can be quite important. Some of the recommendations in the past have recommended extreme
sodium restriction that doesn't work and may be dangerous. And again, moderate sodium
intake for most people is fine, but it's a tool in your toolbox if you wanna give it a try, especially if you're not overweight, and if you don't drink that much, then it's third on the
list and it's worth a try, and I'll come back to that in a minute. There's something called the dash diet, which has been around
for about 15, 20 years, which is basically just
a heart healthy diet. So all the principles
of eating a healthy diet with mostly plants, not too much real food and relying on mostly
fruits and vegetables, whole grains, small amounts
of meat, fish, and fowl, nuts and oils, and so on, a Mediterranean type diet
or a heart healthy diet, that's been shown to lower blood pressure.

And in fact, it's additive
with sodium restriction. So if you combine a heart healthy diet and sodium restriction, the blood pressure goes down further. Physical activity can
lower blood pressure. We recommend physical
activity for everyone anyway, as I like to say, physical
activity is Biblical and that means you should
do it six days a week and one day of rest. The recommendations are
30 plus minutes a day. And that if you're start sedentary
and you get to that point can lower the blood pressure by five to 10 millimeters of mercury. And as I implied earlier, a habitual caffeine consumption
or coffee consumption is not associated with the
risk of high blood pressure. In fact, coffee consumption
seems to be the Teflon substance that it's not been shown to
be bad for almost anything, but certainly the studies
that have looked at mortality, heart disease risk,
cancer risk, stroke risk and the like, have shown
caffeine to be not associated with bad outcomes in general.

Now clearly it can make you irritable. It can give you GI problems. It can cause atrial
fibrillation in some people. But in general, when
you look at populations, caffeine as a fatigue, mitigator, as we call it with the
residents is safe and effective. Once upon a time when I was
a nutrition graduate student, I used to say, and I had
a slide that said this, it was a while ago,
that a third of the salt in the human diet comes
naturally occurring in food, a third comes from food processing and a third comes from us
as consumers at the stove or at the table.

And that now is just totally wrong. We've evolved over those 40 years to the point where our diets are different and our sodium sources have
changed to the point now where processed and restaurant foods account for almost 80% of our salt intake. So still a small amount from
naturally occurring in foods and still some at home. But if someone tells you
or someone suggest to you or for your own reading suggests that you wanna be in
a lower sodium intake, worrying too much about
what you do with the stove or the table is most
likely the wrong tactic.

And what you need to do
is not purchase anything in a bag or a box or a can, unless it says in really big letters, low salt, because anything
in a bag or a box or a can is high salt, unless it says otherwise. And so the whole story of
when you go to a big market, only shopping on the
outer aisle of the market, where the produce is and
the dairy and so forth makes very good sense. So don't limit your consumption
of things in general that are in a bag, or a box, or a can, if you're concerned about
your salt or for that matter current dietary recommendations.

Secondly is restaurant food and other package and prepared foods. So a lot of the services that
are out there delivering food, but particularly restaurant food. I don't know if any of you have gotten into the game of weighing
yourself every day and the night after you
went to your favorite, whatever restaurant that's
particularly high in soy sauce or whatever, and your
weight goes up four pounds and you say, "This is not possible. "I didn't eat anything yesterday." But then you realize
you went and had sushi or your favorite Thai food restaurant. And it was all because
of the sodium intake. So those changes in weight
are all salt and water, so a couple of days later it'll come off. But that's showing you how
much sodium is in that food that you ate at the restaurant.

And the worst culprit
of course is fast food. So not to pick on Asian cuisine, but fast food is by far and
away the biggest culprit here. And of course in our
society, that's a concern. So sodium restriction is if you're eating a mostly plant diet and you're
eating your nice tomatoes and you wanna put some salt on it and that makes you more tomatoes, that's a good thing to do. Or if it helps you consume your
lettuce and your big salad, do it because that's healthy, but going to a fast food
restaurant or buying food, that's in a bigger box or can is not. All right. I'm gonna move next to some of the clinical
questions that are most on the mind of clinicians
working with patients with high blood pressure in
terms of medication management, labeling and so forth.

And most of what we know
about high blood pressure over the course of the last decades, most of all of my career, have been from an entity called the Joint National Commission. And this is a NIH brought
together panel of experts. They meet every five to seven years or so, and they come up with
different recommendations, and over the years they've defined what's a normal blood pressure. They've recommended certain
types of drugs over other drugs and so on. And the most recent one
was a few years ago. It was the eighth version of this, and they asked three questions and this was good because they were three really good questions, the three questions
that we all care about, which is, does treatment of blood pressure at a certain level of elevation work? If so, how low should I treat it? Good questions. And third, what medication should I use? Does it matter? And what they did was, which was different
than the seven previous Joint National Commissions, is they only looked at what we call Randomized Clinical Trials, which is the highest level of
medical scientific evidence, where there's a control group, a blinded evaluation of large
populations of patients.

And there had been several dozen of these that met the criteria
for various questions related to high blood pressure. And they came out with
nine recommendations. I'm not gonna read them all. I'll summarize. The one that was most surprising, I wouldn't call it controversial at first, but it was definitely a surprise, was the recommendation that
for people over 60 years old, which is a lot of the population that has high blood pressure
in the United States, that we could use 150 as our
cut point rather than 140. So this was really great
news for primary care and really great news for patients. Because if it meant we can let
people ride a little higher, then that means one less
medication, typically, less side effects, less cost and so on. So this was a very good recommendation, very popular recommendation amongst the primary care community, but others didn't react so
favorably as I'll show you.

And they recommended lowering it below 150 and also lowering a second
number, the lower number, the diastolic blood
pressure to less than 90. So this was a surprise, but favorable, and it wasn't pulled out of the sky and I'm not gonna review this, But each of these abbreviations stands for a really big,
well done, publicly funded randomized clinical trial of the treatment of high blood pressure. And so they looked at a
very large body of evidence in order to make this conclusion. So it was very, what we
would call, evidence-based. The other recommendations
were not as controversial. They said for everyone else under 60, then you should use 140 as your cut point. Or if you're treating both the high number or the low number using
90 as the low number. I should just point out it
turns out that the high number is more important than the low number. When I was in medical
school, that wasn't the case.

We mostly focus on the lower number, what we call diastolic hypertension. But it turns out that
systolic hypertension is the most predictive of
cardiovascular disease, heart disease and stroke. At the time these studies
were being analyzed, the diabetes community
was trying to suggest that lower values would be better, but they reviewed the
evidence carefully and said, even in diabetics, it
doesn't really matter. People with kidney disease, CKD stands for Chronic Kidney
Disease, didn't matter, You could use 140. And people were pushing that in the African American community, where there was a lot of risk
associated with hypertension that lower numbers might be better. They looked at that literature
and said it doesn't matter. And so basically they
concluded that 140/90 was fine for everyone, that there were many patients over 160 that you could let ride a
little bit and drift up to 150.

Although they also said if
the patient was under 140 and well-controlled, that was fine too. So you were given some flexibility
for people over age 60. The medications they
recommended were four, and previous recommendations
have favored one class over another. They were a little bit more agnostic, gave us a smorgasbord of four medications, except it was really four
ways to get to three, because two of them
shouldn't be used together.

So the four categories are thiazides, which are water pills, weak water pills, but
which have independent blood pressure lowering effect. CCB stands for Calcium Channel Blockers. I'll give you the specific names of some of these in a minute. Those work. ACEI stands for ACE Inhibitor and other I'll give you the names. And the fourth category are
angiotensin receptor blockers, or ARBs, and they also can be used
as the first class of drugs. The one corollary here was not
to use ACE and ARB together. So you could use ACE or ARB,
either first, second, or third, and then thiazide first, second, or third with calcium channel blockers
for a second or third. So that was sort the modern menu.

And that was again good for patients, 'cause there were a lot of
medicines in these classes, good for physicians, 'cause they're medicines
we knew how to use. You'll note or you may note
that one class of medicine that's not on this list are beta blockers. And beta blockers have been
used for high blood pressure for many, many years, they're very good for other conditions. But when studied compared
to these four drugs, they're not as effective
as a single therapy. But that's a little misleading
because they're excellent as the third or fourth drug or they're excellent if you
need it for something else. So it still lowers your blood pressure, just not quite as evidence-based in terms of preventing
strokes in particular as these other four classes of medicines.

But it's still on the list,
we use it all the time. It's very effective way
to lower blood pressure, but just not as the first or second drug as the main blood pressure
lowering treatment. And something that not everyone knew, although it's been in the
literature for several decades is that ACE inhibitors and
angiotensin receptor blockers do not work as well in African Americans as the other classes of drugs. So they specifically went
out of their way and said for African Americans, we recommend thiazides or
calcium channel blockers first. Again that's also a little misleading because many patients need, most patients need more
than one medication. And again, once you've
gotten to drug number three, you begin to go to back to
ACE and ARB very quickly in African Americans, but you would start
with thiazide diuretics or a calcium channel blocker
as your drugs of first choice.

And in kidney disease, that's the one disease with
specific recommendations, especially if you're spilling
protein in the urine, then ACE inhibitors and
ARBs have a long history of helping preserve kidney function. But that's really more in the context of having chronic kidney disease than just bland essential hypertension. So those were the recommendations and we read this and said,
all right, that's sensible. They asked the right questions, they looked at the right body of evidence. These are patient-centered,
good for primary care, everything was good. And then the sky fell. (audience laughing) But these are the medicines that, just to show you some of the names, these are not the brand names, these are the generic names
or the chemical names, but you may still recognize them 'cause many of these medications have been around for decades. They're all generic, they're inexpensive. they're on everyone's formulary, not necessarily all of
them in each category, but one from each category
is on everyone's formulary. And so it's pretty easy to find
an ACE inhibitor that works.

An enalapril or lisinopril
are pretty common. Angiotensin receptor blockers. Losartan is probably the most common. Valsartan is the one that had
a little bit of imperfections in the synthesis. So that's been out of circulation of late, but there are others in that class. The calcium channel blockers, amlodipine is a common one for high blood pressure. Diltiazem is another one. And then the thiazide-type
diuretics in the United States by far and away, the most
common is hydrochlorothiazide, although some of the others also work. So again, lots of choices, they're cheap, they're easily available. Doctors and nurses know how to use them 'cause they've been around forever.

And so it's a good list. And then there is, I'm not gonna show you, but there's of course, 15
other categories of medicines that high blood pressure
experts and others can use if you need more than
three classes of medicine, although most patients do not. So then what happened, is soon after the guidelines came out, a big study was published, and I've already made reference
to this, the SPRINT Study. This was the one with the
robot in the dark room, measuring blood pressure. It was a really well done study. It was at almost 10,000 men and women. They were over age 50. They had a predesignated
group that were over age 75. So it was well done. To get into the study you
needed a blood pressure over 130, which was fine, and you needed to have a
high cardiovascular risk. And I'll explain that more in a moment, but it's an important
part of this conversation. Interestingly, they did not accept people with diabetes into the SPRINT Study. And that was a little bit puzzling, unless you knew that in the year or two before the SPRINT Study was being planned, there had been another big study funded by the National
Institutes of Health, so a very well done, randomized trial that compared 140 versus one 120, the two blood pressures, in patients with diabetes
to see which was better, and there was no difference.

And so the conclusion was
that 140 was as good as 120, and of course that made it
much easier to treat patients 'cause again, it was one
or two less medications. Each medicine lowers your
blood pressure about 10 points or so on average. So 20 points is a couple of meds. So that was sort of weird
because we already knew that in diabetes, it
didn't make any difference, but they were doing the study again, but had to exclude patients with diabetes. So it was a little bit funny
the way that played out. But it does mean that
the results of the study do not apply to patients with diabetes. Who of course are one of
the groups of patients for whom treatment of high
blood pressure is most important 'cause they're at high risk
of strokes, heart attacks, kidney disease, and so on.

They compared people to get, they randomize people to 120 or 140 similar to the diabetes study. It took an extra medicine
to get people under 120. And it turned out it was
hard to get people under 120. The average was actually 121, which means on average,
about half the patients couldn't get below 120, even though they were
getting free medicine, being seen by their clinician regularly more frequent than you would see someone in a normal clinical practice and so on. So that was interesting. Also that people couldn't
actually get less than 120, especially this cohort of
somewhat older patients. And this is the diabetes study. I won't go over it in detail, but again showed that
there was no difference between 120 and 140
before the SPRINT Study. Now, the SPRINT threw us a curve ball because the results were positive, that is to say when they
looked at all the events associated with high blood
pressure, that is stroke, heart attack, non-fatal
stroke and heart attack, death from stroke and heart attack, it turned out that there were less events in the group that was treated to 120. So this was a positive
study suggesting that 120 was better than 140.

But this was a little counterintuitive 'cause we already had six or seven studies that I showed you 10 slides ago that said, it didn't really matter. We had this big diabetes study
that said it didn't matter, but here was this new
study that said it matters. And then the hooker was that it also led to less mortality that people
died less so often at 120, then one 140. So this created two
different conversations. So there's a group of people who thought that SPRINT was the end all, and that affected the
way you look at this. Other people looked at this
is an unexpected result.

We're not sure what it all means. And the conversation
continued and got louder. There were a lot of side
effects on the SPRINT Study. These were things they looked
at carefully in advance. There was 67% more risk. And these were serious side effects. The criteria for this was side effects that the clinician
thought was serious enough to send the patient to
the emergency department or might be life threatening. That was the way the criteria was defined. So these are real low blood pressure. 67% more syncope, that is passing
out, losing consciousness, a third more of blood
chemistry abnormalities, a third more and kidney
problems, two thirds more. So there were a lot of side
effects, but nonetheless, the overall effect was beneficial. And it's a little hard to
explain the concept here, but there's something in medicine when you think about a lot, which is called the
number needed to treat. And I'll show you this
graphically in a couple of slides, but basically it's a way to put the odds of you personally benefiting
from an intervention. So remember these studies are
in populations of patients, but now you and I are
sitting across the table deciding what to do for you.

And so what's the likelihood
that you will benefit given what we know about these
populations that benefit? You're with me on this? It's a confusing subject, but
it's a way to put some numbers on the concept of better versus worse, and quantitated so that people can make
individual decisions. And I'll show you this graphically, it'll be clear in a minute. But in general, the number needed to treat was about roughly a hundred, depending on what you're
measured over three years. So that's about 300 over
the course of any one year.

So it means that if you and I
are sitting across the table from each other, the odds are 299 to one that you're not the one
that's gonna benefit. You're with me on this? So the population
benefits, but you may not. In fact, the odds are you won't. And that's just the way
medical science works. Similarly, the number needed
to harm is about the same. So we get some benefit, we get some harm and you'll have to decide
for you, which is better. Now, of course, in the
way this study was done, the benefits are better
than the harms, right? The benefit included heart
attacks, strokes, and death. And the harms, the harms are things like feeling lightheaded and falling down and having an abnormal blood test. So they're not the same, but it is worth noting that
the frequency was similar. These are all comments I've already made. And the last bullet though, is that when you look at
how the SPRINT Study applies to the community at large, to all of you, statistically, they're only
about one out of six of you that would meet the criteria
to have been a subject in the SPRINT Study.

In other words, whether
it's age or other diseases or what your cardiovascular risk was, whether you had diabetes, all those things were
factors that determine whether you can enter the study or not, and only one out of six patients
with high blood pressure were able to enter the study. So again, the generalized stability to the community at large is modest. And here are some of the risk factors. And so there was no one who had diabetes, no one with stroke, no one was frail, and no one who was, let's
just say under age 50. And as I mentioned, there was free care, frequent visits and so forth. And this very careful measurement that was lower than the usual
measurement, if you remember. Then the other thing that
was really important to know is that these were very high risk patients and that many of you have
probably gone to websites and measured your 10-year risk
of cardiovascular disease, of having a stroke or a heart attack. There's a very good
one on the Mayo Clinic, it's called the Mayo Clinic
Statin Decision Site.

If you just Google Mayo Clinic Statin, it comes up, and you can put in your
various risk factors and calculate your 10-year risk. And we use it in clinical
practice a lot to decide who needs a statin drug
for them for their risk. But it's also relevant
in this conversation about high blood pressure. And in fact, to enter this study, you needed a 10-year risk of 15%, and in fact, most people had 20%. If you've had a heart attack, your risk of having an event
in the next 10 years is 20%.

So 20% is a high number
in this conversation. It's like, you've already
had a heart attack. And so these are people who are on the fairly far along spectrum of risk of cardiovascular disease. And here's a cartoon. It doesn't project super well, but what this is trying
to say is bring to life that concept of number needed to treat. And what I mean by this is, so each little gray box
represents one person.

And if we have, say on
the left hand side here, a thousand people, we can show who are then
treated for three years to a blood pressure goal
of 120, rather than 140, based on the data from the SPRINT Study. We know that 16 of them
will not have a heart attack or stroke in the three year period. It's the same as the
number needed to treat. I've just done some arithmetic
and made it a cartoon. But the point of this, the
way to think of this, again, if you think about odds, if you started as one of the gray people, the vast majority of the
gray people stay gray after three and a half years of being on two and a
half medicines, right? Only a very small number become blue. And that's that idea that
what happens in populations is different than what happens
in an individual patient.

You're with me? So this is a very intriguing way to think about medical interventions. And you can do this kinda
chart with anything. And we do it with cholesterol, we do it with a lot of
cardiovascular management, but you can do this with
lots of other things. So if y