High Blood Pressure (Hypertension) and It's Management

and this afternoon we of dr. goldstein speaking to us on how to manage your hypertension this will actually be dr. Goldstein's last patient education session with us he's going to retire this July after many years of service here at st. Michael's so we're very happy and proud to have him sharing his time with us today and we all wish him well his retirement this afternoon also after the session if you wouldn't mind filling out a form an evaluation form and just giving your suggestions as to what titles topics you would like to see for other sessions in the future and we are starting to videotape all of the sessions that we do so that we can upload them onto our website so people can look at them at other times and also people that aren't able to join us this afternoon they're able to also receive all the information that you receive today so we're going to try and not have anyone in the audience videotaped it'll be just dr. goldstein but if anybody happens to slip in there we do have a consent form that you will have to sign before you leave today just so that you're aware anyways without further ado I'd like to welcome dr. Goldstein for this afternoon's talk and away we go okay thank you all for coming now let me know if you can't hear me and all I'll use the microphone but generally I like to wander around a little bit so we're starting out without the slide presentation because the technology has failed but that's a nice thing about humans as compared to computers humans always work whereas computers sometimes do and sometimes don't so we're talking about hypertension hypertension means high blood pressure people who think well gee it has something to do with being tense well not really although if you're tense sometimes that will raise your blood pressure but we're really talking about high blood pressure and high blood pressure is really very common and the incidence of high blood pressure progressively increases as we get older so don't be surprised if your blood pressure is very acceptable through most of the time and as you get older it goes up and the important thing about blood pressure is it doesn't cause any complaints so the only way you really know if you have high blood pressure is if someone measures it and I think a number of you have hide your blood pressure measured today by Bottari and you may know that you feel fine but your blood pressure is up anyway and I'm amazed at the number of my patients who say oh I know when my blood pressure is up you really don't and that's why blood pressure is is commonly called the silent killer because it does a lot of damage and it doesn't really cause any complaints at all so if you're at high risk of high blood pressure you should periodically check your blood pressure and many people have their blood pressures measured at home which is the best way to do it so anyone who has a drug plan usually your drug plan will pay for you to buy a high blood pressure machine and if and when we eventually get the computer working I'll give you a website that's the website of hypertension Canada and it lists all the blood pressure machines that it approves the one that I think is a very good one is Omron om r om and if you're looking for a blood pressure machine I would suggest you buy an arm Ron machine it's a good one it's guaranteed for life so if it stops working you can bring it back and they'll they'll either fix it or replace it for you how many of you do have your own blood pressure machines actually that's excellent so probably at least half if more than half have their own blood pressure machines that's very good people say when should I measure my blood pressure you should measure it I think first thing in the morning when you get up before you take your pills and then at a busy time of day when you get home from coming from work or shopping or looking after children or whatever you're doing with your time that's a good time to measure it and you should measure your blood pressure in a very stand standard way the way we tend to measure it is you're sitting down comfortably with your feet on the floor and your machine is on the table and you measure your pressure three times about a minute apart discard the first one because the first one's always high and then average the other two and that'll give you a pretty good idea of what your blood pressure is the other thing to do is to measure it say at least twice a day so when you first measure it it's related to not having just taken your blood pressure pills and if you are in the habit of exercising and if you take your blood pressure while you're exercising you'll find that your blood pressure usually goes up wall exercising but it falls really pretty rapidly over the next 10 to 15 minutes after exercise so if you've been exercising wait 10 or 15 minutes before you measure your pressure then people who take pills say when should I take my pills and that's why I like people to measure their blood pressure at least twice a day because it gives us a certain pattern some people's blood pressures tend to be high in the morning when they first wake up and that's important to know so those people should probably take their blood pressure pills at night so they're acting nicely first thing in the morning where if your blood prayer sure is excellent first thing in the morning and tends to go up as the day goes on because you're because you're active and and life is a bit of a rat race and that can put your pressures up or some of your co-workers or your relatives may put your pressure up as well it's good to know that so those people should take their blood pressure first thing in the morning the other thing that's important is you may get your blood pressure at home to be really quite acceptable and you come to the clinic and we measure it as very high and you say well which is right well we don't know which is right but the first thing to do is to bring your machine to where it's being measured and confirm that it's giving you the same information as the machine in the hospital or the machine and the clinic is is giving you and if the - blood pressures are indeed correct then I'm quite happy to go with the blood pressure that you get at home because it may well be that you get a little bit upset as you come to the clinic and that's understandable but most of the time your blood pressure is at home under standard conditions and that's fine but if you get a gross discrepancy between the pressure at home and the pressure where it's being measured in the doctor's office or in a clinic I think it's reasonable to bring your machine to that site and at least show what I like to do is when the patient brings their pressure to me I I don't measure it with their machine I ask them to measure it because there's a certain way you should use your machine and maybe Tara showed you that on the on the cuff but there's generally a diagram on your cuff that tells you where to place which part of the cuff and let's see if this if this cuff tells you yes you see this cuff has a sign here that says artery so that's very helpful as long as you know where the artery is if you don't know where the artery is and cero doesn't help but this is where your artery is right here and if your put your fingers here you can feel it pulsing so where that pulse is is where this arrow on the cuff should be and that's very important because the cuff is sensing your blood pressure and so this sensor has to be in the right place so that's the first thing the next thing to do is if you look around the room we've got people of various sizes and I won't pick anyone out except that some of us have small arms and some of us has big arms and so the cuffs come in various sizes and the way you tell if you have the right cuff is the edge of the cuff has a white line on it here and that white line when you wrap the cuff around your arm should fit in to this area which is marked with arrows as the range so if the if this white line doesn't lie in that area as you wrap the cuff around your arm the cuff is the wrong size and you have to use a different size cuff and it has nothing don't take it personally if someone pulls out a bigger cuff for you some people get aggravated so I try to guess which is the right size before I put the cuff on so I don't have to take it off and put another one off and the person says oh you think I'm fine don't you so here's a smaller cuff and you can see that this one will fit into this range in a much smaller circle than the other one did so make sure the cuff is the right size before you before you measure your cut your your pressure and what I would suggest is make sure it's the right size you before you buy it so if you go to the drugstore and buy the Machine say I want to see the cuff and I want you to make sure it's the right size and it's kind of upsetting that some drug stores will sell you a wrong machine because there's two things they should make sure it's right for you and then they should show you how to use it and the other thing you should do when you're measuring your pressure is you should write down the numbers so that when you go to the clinic or go to the to the doctor's office you can give them the record of your blood pressures so they can see a what they are and be what the pattern is because if it's very high in the morning you want to take your pills in sync with when your blood pressure is high so you'll know that your the blood pressure pills are acting at the right time most of the pills are long-acting and will last for 24 hours but they do have peaks and valleys and some pills how are shorter acting and they have to be taken twice a day so you should be aware of which pills are long-acting and which are short acting and most of the drug stores are quite happy to give you quite a sermon about your drugs when you go to pick them up and it's worth listening to the other thing that's worth knowing about is what the blood pressures mean and that patients will say well which is the more important one the high number or the low number and the truth is they're both important the high number if we say the blood pressure is 130 over 80 that high number of 130 is called the systolic pressure and it means when your heart contracts when the the that can be the cavity that holds the blood which is called the left ventricle when it contracts and pumps blood out the height to which that pressure rises is 130 then your blood vessels are elastic so between beats the the blood vessels constrict and maintain the pressure elevated so the pressure doesn't fall down to zero between beats but falls down to that lower number which is 80 which is called the diastolic pressure both of them are important so the the systolic pressure the height at which the pressure goes that puts stress on the blood vessels that are going to the organs and then could stress on the organs themselves so that that pressure is quite important and then the lower pressure is important too because it's at that lower pressure that the blood flow is flowing through the organs so what's the target it's interesting that the targets of blood pressure have been changing and the way they're changing recently is blood pressure targets have been falling I've always had a philosophy that blood pressures like golf the lower the better and and that's becoming more and more true one used to say well the patient's older so let's let them have a higher blood pressures well that's been shown to be wrong and I don't think we should discriminate against older people particularly as I get older I think that it's fair enough to treat older people the same way we treat younger people so generally when used to say the target of the blood pressure is 140 and we should try to get the two if it's above 140 it should be lower well we're now recognizing that 140 is fairly high and more recent studies have shown that probably we should be aiming for blood pressures at least 130 rather than 140 and there's the most recent study the Sprint study which aimed for blood pressures even lower 120 and the truth is that the patients with blood pressures of 120 did better than the patients with blood pressures over 120 so I think we can say that maybe blood pressure is like golf and maybe the lower the better within reason I think you should feel well some people say they don't feel well at a blood pressure of 120 but feel better at a blood pressure of 130 fair enough so those people should be at 130 but I think everyone should be less than 140 and probably around 130 now you'll find that your blood pressure varies a certain and that's fair enough and that there's no doubt when you're very active your blood pressure is high those of you who have done an ambulatory blood pressure session where you wear a blood pressure for 24 or 48 hours and it measures your blood pressure every hour or so will recognize that your blood pressure varies quite a bit and you'll find that when you go to sleep your blood pressure Falls and it usually Falls about 20 millimeters of mercury lower than it is during the day and in fact we have a nocturnal dialysis program here where patients sleep on dialysis and the nurses used to get quite upset that all the blood pressures were all the patients were hypotensive and I asked them to stop taking the blood pressure when the patients are asleep or to go home and wear a cuff yourself and see what your own blood pressure does when you sleep because everybody's blood pressure or almost everybody's blood pressure falls when they sleep I'm that's called dipping and that's normal and your blood pressure should normally fall when you sleep and if it doesn't then that that's a sign that your blood pressure isn't regulated normally as well as as the normal or non high blood pressure patient with hypertensive blood pressure is regulated and that's why some people take some of their blood pressure pills at night and that's to try to mimic that normal fall in the blood pressure during the during the normal cycle where our blood pressures fall as we sleep so that's important thing to to be aware of let me tell you about another what mr. Trump would call false news and that is what's the role of salt in high blood pressure and I think that most of you probably have a feeling that salt is bad and everyone should be hassled every time they use a salt shaker and that's not really true the truth is that people with salt sensitivity should limit their salt intake and a good percentage of people with high blood pressure but fall far from everyone are sensitive to salt so I think a general principle is if you have high blood pressure be sensitive to how much salt you use and if your blood pressure is too high cut back on your salt and watch what happens to your blood pressure if your blood pressure isn't high and you add salt and it doesn't go up and you like the taste of salt then I say you salt and anyone who's eaten with me knows I happen to like salt but my blood pressure is perfectly normal so I get annoyed when people hassle me about how much salt I use so don't hassle people who use salt if their blood pressure's normal salt is not bad for everybody salt is bad for some people and it's bad for some people who have high blood pressure so that's a sort of a dogma you should be aware of if your pressure how many people here have high blood pressure probably maybe two-thirds of people have high blood pressure and that's more than the general population and that's probably because there are people here who tend to have kidney disease when you have high blood pressure we talk about risk factors and people who have a risk factor for high blood pressure should measure their blood pressure periodically because I said your blood pressure doesn't cause any complaints so who has who has risk factors for high blood pressure for the first for the first thing does anyone do you want to log in or do you want one of us to log in who are the people who are at risk of high blood pressure well probably the worst thing for you and that most of you fall into this category is you don't choose your parents properly and that's and that's a problem your genes are one of the most important determinants of high blood pressure so the vast majority of people with high blood pressure have genetically mediated high blood pressure so they have a family history so if you have a family history of high blood pressure you should periodically reassure yourself that your blood pressure is normal the next group of people anybody know people with diabetes though people with diabetes are at risk of high blood pressure so anyone with diabetes should periodically measure their blood pressure and ensure it's normal the next group of people people with kidney disease so anyone with kidney disease is at risk of high blood pressure and they should measure their blood pressure periodically and know that their blood pressure is under good control and under good control let's say is 1:30 or less next people who are obese obesity raises the blood pressure and they are at risk people who have obstructive sleep apnea so you say wow that's a big $20 word what's obstructive sleep apnea how do I know if I have it well people with obstructive sleep apnea are generally people who snore people particularly whose breathing is interrupted when they snore so you if you have someone living with you who snores and periodically stops breathing for 5 seconds 10 seconds 15 seconds and you start wondering boy they're going to take another breath or aren't they those are people who have obstructive sleep apnea those people tend to be tired during the day so they may fall asleep during the day there's some people who fall asleep at their desk during the day some people fall asleep while they're driving even more dangerous but obstructive sleep apnoea oh you did it good great thank you very much so this is the website for those of you who have computers if you just want to write down this website this is the website of hypertension Canada you'll find lots of useful information here and the two areas I'd suggest you go to are this one hypertension in you which is generally made for for the public who have hypertension and the other one is this one that's recommended devices and it will give you the list of all the recommended blood pressure measuring devices that are available to you if you have one that isn't on that list but it's working well fair enough but if you're going to buy one buy one that's on that list so we talked about the systolic and diastolic pressures what are they we'll consider yourself pumping air into a tire here and this is the the as you pump down this is the pressure you reach with the pump and then the elasticity of the tire is going to fall somewhat but maintain the pressure and it's going to fall to 80 so that's the systolic and diastolic pressures and that's what they mean the height to which it goes when your heart pumps and the height to which it falls as the elasticity maintains the pressure we always want to see your pressures less than 140 over 90 and as I said we're now aiming more for an ideal between 120 over 80 and 130 over 85 some people most of us like to be ideal some people are happy with just being acceptable but I think most of us would rather be more unacceptable so why is my blood pressure elevated as I said you didn't choose your patient your parents properly you may have kidney disease which is a risk factor you may have diabetes which is a risk factor sleep apnea which we talked about the only way to die you can be very suspicious of having sleep apnea if you snore and if your breathing is interrupted particularly if you're drowsy during the day and especially if you fall asleep during the day and if you fall asleep driving you better do something about it so sleep apnea is certainly a risk factor obesity we talked about smoking is something I didn't get to as we were talking about risk factors anyone with high blood pressure who smokes is crazy really smoking does the same damage to blood vessels as diabetes does and as high blood pressure does so smoking in general is bad but smoking if you have diabetes or high blood pressure is insane so you're really if you're smokers I'm not saying it's easy to quit but you really should quit alcohol also aggravates high blood pressure so one drink a day is acceptable for women two with men and you can say here's another case where we're discriminating against women I've had enough of that but that's those are the are the the metrics that are generally suggested but generally if you have high blood pressure and cut down on your alcohol intake you'll find that your blood pressure Falls salt we've talked about if you have high blood pressure and you use a lot of salt cut back if you have high blood pressure and you and you you cut back on your salt and your blood pressure is staying quite normal that's fine you can use a little salt and if it stays normal fine not everyone is is aggravated by salt stress does aggravate your blood pressure and certainly if your your your teenager is upsetting you take your blood pressure say look it's elevated look what you're doing to me you better cool down and stop doing what you're doing you can use your blood pressure as a tool if that helps chances are your teenagers not gonna care so as I said high blood pressure is called the silent killer I'm sorry we're repeating some of this but in a way I'm glad I was able to carry on without the slides so don't count on the way you feel to tell you if your blood pressure is high or not use the machine to tell you we just can't tell what our blood pressure is so what does high blood pressure do will it put stress on the blood vessels which then put stress on the organs and there's three major organs that suffer from high blood pressure the brain and that's called a stroke the heart and that's called a heart attack and it can give you heart failure and the kidneys which suffer with kidney damage as a result of high blood pressure he also can do damage to the vessels going primarily excuse me to the legs and people get cramps in their legs when they walk they stop walking the cramp goes away and they carry on that's because the blood vessels to the legs are getting narrowed because of the high blood pressure or because of smoking or because of cholesterol deposits and you can tell those people often because you'll see them walking and they'll stop and they'll look in the window and then even though it's not a very interesting window and then they'll carry on and they'll be looking in another window and those are people that's called claudication and that's related to high blood pressure or something else damaging the blood vessels the other area that is often bothered with high blood pressure or the eyes because the blood vessels to the eyes get narrowed and that can impair your vision and so you can get visual damage related to high blood pressure and the area that that people perk up their ears is erectile dysfunction people don't like to get a rectal dysfunction certainly high blood pressure can cause erectile dysfunction the other thing though that causes it in truth are some of the blood pressure pills and so we have to be honest about that and some people notice that their medication does that that to them and we try to deal with it there's some evidence that dementia is also aggravated by high blood pressure and so when what really wants to try to control the pressure for all these reasons there's good reasons to have your blood pressure in a good area the other thing that's important is to recognize that most people with high blood pressure don't know about it so this area shows that there are thirteen percent of people who are well controlled that's really disappointing I'm trying to find the arrow here so I can use the mouse but it's I'm not very successful so anyway thirteen percent this this lower quadrant here are people who are well controlled it's really disappointing number twenty two percent of people know they have high blood pressure but they're not well controlled why aren't they well controlled one of the major reasons for good blood pressure control is not taking the pills so the thing to do is to try to get in the habit of taking your pills regularly I find the best way to take pills his first thing in the morning so get all your pills together the vast majority can all be taken together take the handful of pills don't count your pills count the impact of the pills I tell people and someone just complained to me today about the number of pills they were taking and I said be happy that you have a problem that can be dealt with with pills many people have problems that can't be dealt with with pills and they would love to change places with you so we're very lucky that we live in an era now where you can take pills and deal with your problem and that's great so don't count the pills just look at the impact and if you're getting better with your pills that's great the benefits of of measuring your own blood pressure at home as you can see what happens as you manipulate your pills and you can see gee I'm leaving out some of my pills my blood pressure is a lot higher that's a learning experience you don't want any of that list of complications so take the pills to control your pressure there's 21 percent of people who have blood pressure they're on treatment but they're not adequately controlled IMATS aiming for the right target so by measuring your pressure you know if you're controlled or not and there's still a large number of people who are unaware that they have high blood pressure and that's a problem and that's why when you go into the drugstore stick your arm in the machine even if you think your blood pressure's normal the kidney foundation used to run clinics and factories and offices where they would take everyone's blood pressure and they always found people who were unaware of the fact that they had high blood pressure and this was a real investment in their future because they found out they've got a disease that's going to hurt them and they can benefit so if you get a chance to get your blood pressure measured don't walk away from it often you'll see in the mall there are people from various organizations taking blood pressures have it done it's good for you to know either that your blood pressure is normal or if it's high but if it's high they're not gonna hurt you they're just gonna say go to your doctor to get it checked and if it's high several times then you should be on treatment so that's very important you don't want to be part of this group that doesn't even know what their pressure is so we talked about these risk factors family history diabetes and chronic kidney disease are three big ones so and we've talked about this as well you should monitor your blood pressure periodically if you have a risk factor even if it's known to be normal that's good how often is periodic if it's perfectly normal probably at least every three months if you're on pills and it's normal I would suggest you check in every month to ensure that it's normal the first of the month the 15th of the month you decide when but just measure it periodically you can measure it at the drugstore if you have a machine measure it at home but be sure you have the right size cuff if your blood pressure is well controlled monthly and if it's not well controlled measure it every day and see if it's period if it's really staying not well controlled you tell someone I get very annoyed when someone comes to me with the three-month list of their blood pressures uncontrolled all the time that's three months that they've been at risk and not doing anything about it there's no point in measuring your pressure if you don't share it when it's abnormal if it's abnormal once don't worry about it measure it again but if it's abnormal several days in a row call your family doctor and let them know if they don't respond then call someone else who might respond to it but having high blood pressure over a long period of time does damage so don't let it happen that way don't keep it a secret share your blood pressure if it's abnormal we talked about the size of the cuff and how you tell if it's right or wrong we talked about how you measure your pressure and I'll just let you read it but these are all things that I said and write the measurements down so you can share them and if it's how I measure it at least twice during the day so can see a pattern so how do you bring your blood pressure under control given the fact that it's high there's certain lifestyle modifications that you really should pay attention to a healthy diet and we're going to talk a little more about the diet in detail and Carol our dietitian is here to help us deal with the diet ideal weight so those of people who are obese and you know who you are strive to get your weight down it doesn't just impact on your on your blood pressure it also impacts on your joints so your hips start to hurt as they're tearing all this extra weight your knees start to hurt I'm the older you get with heavy weight the more likely you are to have joint problems and that's an issue as well regular exercise is good regular exercise is not the way to lose weight regular exercise is good for you it maintains your muscle mass it keep do we normally lose muscle mass with age so if you exercise you maintain it but exercise is not the way to lose weight to lose the way to lose weight is control the things that go through your lips and the main thing is carbohydrate Carol may have more specific information for you but generally watching the carbohydrate which is the bread the potatoes and the rice is a good way if you're trying to lose weight to cut back on your on your weight moderate alcohol has an impact if this this table gives you some idea so weight loss for example if no sorry I don't tell you how much you lose but there there are tables that will tell you given a 10 pound weight loss how much it's probably four or five millimeters of mercury a change in in blood pressure probably that website will give you that information certainly if you're smoking you should quit if you have sleep apnea treat it and the blood pressure will improve as well as you will feel a lot better those of you who wake up and aren't really restored and feel wide awake when you get up in the mornings you may well have sleep apnea dealing with stress is not necessarily easy personally I find the best way to deal with stress is to exercise so regular exercise is a good way if you find you're in a stressful job or stressful situation at home doing some regular exercise is a good way to deal with that then if all of these things still keep your blood pressure up we have medications and I said some medications do have side effects in fact many of them do I must say I laugh when I hear the on TV when they talk about these drugs and they list like 30 things that they may cause you wouldn't take an aspirin if someone listed all the things that an aspirin might cause so drugs do have side effects but they don't affect everybody they affect some people and so don't sort of read the side effects and so I'm not taking that drug look at the things it does but we have feel good and feel bad medications the truth is we don't use many feel bad medications anymore we used to use them all the time because that's all we had but we don't use those drugs anymore unless people are really having troubles with the usual drugs so the groups of drugs that we have that generally do not cause people to feel bad or water pills or diuretics they cause you to lose salt and water and we only use those in people who tend to retain salt in water some people with kidney these loose salt and some of you although I don't see anyone here but there's some of my patients who I will tell them eat more salt because the kidney filters a lot of salt a day and reabsorbs most of it if you have kidney damage some people with certain types of kidney damage waste salt and tend to lose salt in their urine and those people need to take extra salt particularly if they're taking certain drugs that need an adequate volume of blood in the body so water pills are a commonly used drug along with them the drugs that we use most commonly are angiotensin kurtik converting enzyme inhibitors that's what a CEI stands for our angiotensin receptor blockers they're the two groups of drugs that are generally considered first-line drugs now and examples of those the ACE inhibitors are a CEOs and in prill ramipril occup real those kind of drugs and the AR bees and in our time losartan Ulmus are tan those drugs and they not only lower the blood pressure but some of you might be on those pills and you might say my blood pressures even low why aren't they reducing it because they also reduce the protein in the urine and that's one of our major goals those of you who have diabetes and have a lot of protein we really struggle to get that protein down and we use those drugs to lower the protein in the urine even though the blood pressure may be quite normal the other group of drugs are called the calcium channel blocker agents and those are our amlodipine and diltiazem are the two drugs that are used as calcium channel blockers to help lower the blood pressure and some of you may be on those may a side effect that they caused that or any problem is swelling of the ankles the angiotensin converting enzyme inhibitors may cause a cough and a lot of you have been on them in coffin we take you off them and put them on put you on the I'm sorry I don't have a pointer the angiotensin receptor blockers ah here's a pointer the angiotensin receptor blockers if you have a cough the other thing some of them do very rarely as they might cause swelling of the lip or swelling of the tongue and if you get those you should stop them the next group of but drugs are beta blockers they tend to slow the heart sorry they tend to slow the heart and metoprolol they end in awls so metoprolol Bazaar Lal are those family of drugs they're also very good for the heart people who've had heart attacks are almost routinely put on that family of drugs so you might be on those drugs even though your blood pressure is normal if you've had a heart attack other drugs that are sometimes used sorry our alpha blockers if your blood pressure is close to being controlled I would use an alpha blocker or vasodilating drugs like hydralazine a very potent drug is minoxidil and I'd use those and in people who are having high blood pressure that's trouble to get under control that's a drug that often will bring the blood pressure under control women don't like it because it causes hair growth the centrally acting drugs are part of the field bad drug sorry when I try to use the pointer that's changing the slide these are drugs that have more unpleasant side effects but they they are sometimes used in people who just aren't responding to other drugs and these are clone adine and alpha methyl dopa chances are none of you are on those drugs some of you might be but those are the families of drugs we use and why we reuse them and what if you have side effects side effects do occur sometimes they're short-lived so try to tolerate them if it's if it makes you drowsy for a day or two and often they do just try to tough it out because that will pass off sometimes just cut the dose back a bit and see if that helps the side effects and then increase it slowly some people with the smallest side effect they stop the drug and I think that's unfortunate because some of the drugs are having big benefits and to stop a big benefit for a small side effect doesn't make a lot of sense so give the drugs a chance and if it's going to prevent a stroke and gives you a minor side effect maybe that side effect is worth it so keep that in mind if there's GI upset they have set your stomach take them with food often that minimizes it if it's if the pill makes you drowsy take it at bedtime and then the drowsiness may help you sleep and you get a second benefit from the side effect if you get dizziness with the saw it with a drug check your blood pressure often it may be low in other words the drug is working maybe a little too well so if you feel light-headed especially when you're standing up check your blood pressure and if it's low let the healthcare team know and what they might do is just reduce the dose and you'll feel a lot better and if all those don't work tell the healthcare team don't just stop the drug because if you stop the drug you may suffer from that and it's better to let the team know and they might give you a better solution than just stopping the drug by the way if anything if questions arise just let me know so when should you take your drugs well as I said most of them are long-acting and can be taken once a day so people who are on dialysis hemodialysis we like them to take that pill at the time when they're getting home from dialysis every day so it's not having its major effect at the time when they're on dialysis and might drop their pressure so if they're on dialysis in the morning they should take the pressure at noon when they get home if the blood pressure pills if they're on dialysis at noon they should take the blood pressure pills in the afternoon every day and it's important to get into routine so you take your pills every day as I said the Communists cause of poor blood pressure control is forgetting to take the pills and sometimes we've talked about taking some of them in the morning and some at night some at night if something makes you drowsy take it at night but also that helps to to replicate the normal dipping of the blood pressure that happens during the night we talked about hemodialysis patients and if you forget to take the pill in the morning and you remember at noon we'll take it at noon don't just not take it take it at noon and still derive the benefit of that particular pill and as I said the Communist reason for poor blood pressure control is forgetting to take the pills especially when you feel good and the truth is most people with high blood pressure do feel good if you're going to headache you'll take a pill for the headache if your nauseating is you'll take a pill for the nausea but if you feel good then you tend to forget to take the pills and that's one of the reasons for not taking them dietary control is one of the major reasons for poor blood pressure control and one of the major lifestyle issues for bringing the blood pressure under control and you've probably heard of the - diet - means dietary approach to stop hypertension and this is the - diet and Carols here to help us discover to talk about the the DASH diet so as dr. Goldstein I mentioned about the diet that the - diet called dietary approach to stop hypertension and as you have noted that no it tells us to eat more fruits and vegetables low-fat free dairy whole grain and use less meats fish poetry's and nuts and those are things that know sometimes with our kidney diet it does not agree with it right so even though the acid you see more fruits and vegetables more nuts that's meats and know some of the things does not agree so as we kind of look through with grains it asks us to have know at least seven eight servings of green a day however they focus on whole grain and often for you being on with the kidney diet is that whole grain when you have you have to think about the potassium the phosphorus in your diet so you kind of have to kind of say okay well whole-grain perhaps maybe not so much maybe we need to look at okay in between the whole grain versus the white flour main breads and cereal which is low in potassium but may not go as with the - die of what sort of the in-between so often we talked about while the middle ground perhaps might be the light rye or the sourdough bread or a quackery bread where I will give you a bit of sir the fiber with no the dash diet perhaps but not the potassium the phosphorus that you may need to restrict so again it's very individualized not necessary everybody has to stay away from whole grain it really depends on what's your level of potassium your phosphorus in your diet vegetables again having lots of fruits and vegetables in your diet is great however we kind of have to think about with vegetables is the potassium again so for example broccoli carrots tomato sweet potatoes Brussels sprouts and other greens yes these are vegetables but within that we kind of have to think about well potassium so in the list of vegetables examples things such as tomatoes sweet potatoes Brussels sprouts maybe something that you kind of have say well wait a minute do I need to watch my potassium and if that's the case then those may not be the vegetable of your choice so again you kind of have to think about you know with respect to your kidney diet what it is within the DASH diet that you kind of have to think twice about fruits typically fruits are good for us so again you know with the example that they have with bananas apple grapes and berries etc these are all wonderful fruits however if you need to watch your potassium then perhaps you know apple grapes berries may be a better choice than the banana oranges or for example cantaloupe all right so in a way it's great with the dash tire but we kind of have to think about what it is of it that it's good for me dairy products typically we know suggest low-fat milk yogurt ice cream and whatnot and you know in terms of serving again you kind of have to think about know with potassium with phosphorus what it is that fits in my diet meats poultry fish to give us protein again we are thinking about no to make sure that they're low-fat as well as now with respect to people who need to be careful not necessarily the potassium perhaps phosphorus is some in your diet and you need to watch out for then you may think about no in terms of the portion size or the type of meat fish poultry so for example you know chicken versus organ meats let's say somebody know liver kidney perhaps us higher in phosphorus then let's say your fish or your chicken or your grumpy for example you look for leaner cuts of meats something one of the dietitians was doing a study here and this the stores are injecting or the vendors are injecting phosphate salts to prolong the shelf life of me and that's something I think they label that is seasoned yeah sometimes there was seasoned or often you might some of the additives that are ends and that are started with Foss pH OS so that's something you kind of want to watch out for writing it at seasoned you might want to take a second look and often now things like deli meats things are processed in order to keep shelf-life or as long as possible they would inject these additives to certain foods okay seasonings and again you know from the - size that the emore sees not someone not legumes however if potassium and phosphorus is something that you need to be careful with then know you kind of have to think about the amount that you're allowed and maybe speak with no dietician that work with you which not would be me or any other dietician in the hemo unit or with that would sort of help you to kind of incorporate this into your diet and keep in mind of your potassium phosphorus there's certain nuts that are lower in the time generally pretty evenly but if you want there is sort of now you couldn't say okay half a cup of is in peanuts how much is in well no so they're generally about more or less the same and same thing with the legumes alright I guess the more tips on the - tips diet again now with respect to you know the fruits and vegetables or low-fat as well as now in terms of your dairy product the low-fat but one thing to keep in mind is that no it's a diet for your blood pressure however you kind of have to individualize it depending on what it is that in your diet you need to watch out for all right great thanks very much no problem and the ACE inhibitors the drugs are bad and trill and the drugs that end in and losartan our drugs that we want to use to lower the protein in the urine but it also effects it tends to inhibit the kidneys ability to excrete potassium so we want your potassium at least in the normal range before we give you those drugs because they're going to raise it and so that's why our emphasis is a lot on potassium because we want it's going to stop us from using drugs that will help you minimize the progression of your kidney disease lowering the protein slows down the progression of your kidney disease so we focus a lot on potassium so that's all I really have to say but be happy to answer any questions or address any concerns you have or if anyone wants to make a comment that's fine too yes fair enough so for those who may have not heard lady is taking all her pills as she should doing everything she should and her pressures still high and so what you have to do is take that Zack same question to the team who's looking after you I don't look after the first thing to do is to examine you some patients on dialysis still have a lot of extra salt in their in their body and the dialysis has to remove that salt so that might be the problem but I don't know because I don't know you but that might be one thing so I'd want to examine you and if you have too much salt in your body adjust your dialysis or give you an extra dialysis to remove that salt to get you down where your weight should be and then see what your blood pressure is some people come to dialysis and in fact their blood pressure rises on dialysis and that's a special situation which we address in with very special drugs so I think the point Carol raised about individualizing the approach holds for blood pressure too some people need a very special approach to get their blood pressure down and so the first thing the team has to recognize your frustration and you got to tell them look I'm on dialysis I'm taking my pills and my pressures not good do something about it well that's a very fair statement it's a very fair statement as I said I have a pill when I'm really having trouble that lowers the blood pressure and sometimes you have to resort to a more powerful pill and maybe that's I don't know who you're the nephrologists are who are looking after you but maybe that's what they have to do well I think your complaint is fair you complaint is fair and maybe if you whisper in my ear who's looking after you maybe I'll I'll have a word with them but I think but I think you're right I think that's a fair complaint you're trying to do your best and you count on the team to help you and you're not getting the help I think you paint your complaint is a fair one yeah I agree with you are you on peritoneal dialysis or hemodialysis well we should be able to get your blood pressure controlled I have a month to get it under control before I leave I've always said the reason I haven't made a blood pressure that I can't get under control yeah did someone here know you does Carmen know you or do some tarah nosers so well I don't so well but I think if your complaint is a fair one we should be able to get your blood pressure controlled and so so all I'll try to find out a little more information about you and see if I can I can help someone get your pressure control good for you good for you well that's fair I don't see any of the nurses here from hemodialysis but we'll find out well that gives me a bit of a clue today is Tuesday so it's so it's noise Tuesday evening so I know who's looking after you okay well thank you for coming and I think your complaint is a valid one I think you've got you've got a perfect right to say hey get me under control any other questions or yes they're not there pounder fit they're coming in from the east from the south north and a drugstore well that's good they should get arrested well I don't say Michaels doesn't have the ability to check the the content of the medication but what some people do is they find their blood pressures well controlled and then they switch to a generic preparation and the blood pressure isn't well controlled so I think it's quite reasonable to ask that the non generic preparation be used that's fair enough and in fact most of the pharmacies now I think and when they're generics available will not substitute if they're asked not to substitute well it's it's often the price is the same sometimes it isn't so I think that one can you know that's a that's a reasonable concern to say gee maybe the generic preparation that there's a component of the government that regulates the pharmaceutical industry that that makes generic drugs and they're supposed to be highly regulated now you know there's lots of bad things that happen despite regulations unfortunately but generally when I prescribe a drug I hope that the patients getting the active drug in fact I don't hope I assume that the patient's getting the active drug and generally if the blood pressure isn't controlled one looks for the basis and if a patient's controlled and then suddenly isn't certainly that might raise the issue of a drug not being active yeah well they I think I think the point to do with that is it should be reported to the government because the government has agencies that regulate all these things and certainly a generic company is inspected and quality controlled so if a counterfeit product is coming in one should understand the route that that gets in well I think the CCBC probably is raising that with the Opposition in the government this is election time when - this is a good time - to raise that that that I have done but the question was asked what would be covered by OHIP and I don't think that we can guarantee that OHIP will cover a non-generic preparation now some companies will give their product and because they're selling if they're selling nothing they may as well sell something better to sell a product at a lower price so I know a number of the companies will say if you can't afford the price of this drug let us know when we will sell it at the price of the generic you wanted to make a comment I think yeah sometimes the price is going to be different I don't think we can obligate the pharmacy to give you the original product at the price of the generic but they but they often are two or three generics and they could switch from one to another if you had a concern about one of them because often there's several companies you know like a Patek makes a lot of generic preparations they're a I think a very reliable company because it's a very big company and a local drugstore may buy it from a smaller generic company and you can then you can request it to be given to to get take a different generic I think that would be acceptable at the usual price that's the price that OHIP covers any yes that's okay good well thank you for coming and thank you for saying that yes sure absolutely and the two places that I particularly encourage you to go to our our hypertension for you which is this one and the recommended devices and that they list probably twenty recommended blood pressure cuffs the one I recommend is Omron and it's about the same price as all the others generally a cold blood pressure cuffs cost about 60 dollars and I believe under certain circumstances the kidney foundation will provide a cuff for someone who doesn't have the ability to buy one and if you wonder about that you could speak to Carmen who's sitting at the back and she sometimes is able to get a blood pressure cuff yes there's it's important the standard way is to take it seated well yeah okay thank you the question was how should one take one's blood pressure sometimes it's different sitting and standing it's often different sitting and standing so I generally the standard way to measure the blood pressure is sitting with your feet on the floor and you're in a comfortable position usually your arms resting on a table that's the standard position anyone who's seen me knows that I tend to get them to stand up and take their blood pressure as well and the reason I do that is to make sure the pressure isn't falling because some people have a disorder of blood pressure regulation that it really Falls when they stand up particularly diabetics and so I like to make sure that someone's blood pressure isn't falling when they stand up you will tend to know because you'll get dizzy so if someone gets dizzy standing up drugs are prone to cause that it's called postural hypotension so people who are prone to that probably should not be taking certain drugs that are predisposed to cause postural hypotension it also happens if you tend to get salt depleted so if you've been vomiting or had diarrhea your blood pressure may fall when you stand up and those people should take some extra salt to stop that but generally you take your blood pressure sitting with your feet on the floor take it three times about a minute apart discard the first one an average of the second and third and the reason they do that is just to make sure that you're not one of those people whose blood pressure tends to fall if it falls a little bit it's okay but some people might go from 130 over 80 to 80 over 60 when they stand up that's very important so that's why they ask good question okay yes yeah so I what I said and what I meant to say is you should be in a routine of regularly taking your pills at the same time every day I find that most people can remember to take their pills first thing in the morning because it's just a hobby to get up you brush your teeth you do a few things to take your pills then the day gets busy and if you don't take them first thing in the day chances are you're probably are gonna forget later in the day some people are very focused and can take their pill at any time people on hemodialysis we tend to tell them to take the pill at the time they're going to come home from dialysis every day so if there aren't a dialysis regimen where they take their pill in where they are on dialysis in the morning and they get home at noon I suggest that they take their pills every day at noon because if they took them in the morning the pill would be having its peak effect at the time when they're on dialysis and may drop the pressure even more so that's why I suggested that some people should take it at a different time the other thing is that normally the blood pressure Falls when you go to sleep so some people who are taking a lot of blood pressure pills like to take some of them when they go to bed so that mimics that normal pattern of the blood pressure falling while they're asleep so the important thing is to take it regularly the time of the day is less important but certain times of the day make more sense for any given person if a pill makes you drowsy take it when before you go to sleep it'll help you sleep - you're welcome okay thank you very much for your 10 one very final question I wouldn't take it after because after a hot shower often your blood pressure is low so if I was going to take my blood pressure related to a shower I take it first good you're welcome good thank you very much for your attention [Applause]

Channel: St. Michael's Hospital

Views: 166,444

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Id: cyWwUVBfX7Y

Length: 77min 44sec (4664 seconds)

Published: Mon Jun 04 2018