Stanford Doctor Discusses High Blood Pressure: What We Know Now and What We Need to Know

[Applause] Thank You Donna for that kind introduction and thank you all for being here today I imagine most of you are either not basketball fans or have a have a working yeah or have a working DVR at home one of the two so I have prepared some slides related to high blood pressure related to current knowledge of the condition and then I have some slides related to things to look for in the clinic coming down the road hopefully in the next few years there are about 36 slides we can spend all of the time on one of the slides or none of the time on all of the slides it's totally up to you I believe the format of this session is that I will try to get through the slides and then at the end we'll save the questions for then but if I go astray or there's some clarification that you have right there and then it's okay if you want to ask at that time that's fine too I'll go ahead and get started oh actually probably one one point here you have to give a lot of lectures when you're at Stanford so I spent a lot of time on symbols you'll see some several symbols throughout this lecture the two symbols I chose for this have to do with what we know now and what we ought to know for a show of hands for those in the audience how many people own or have a blood-pressure cuff at home that they use okay quite a few how many people have a smart watch that they use for anything okay not so many okay okay we'll get to those points as we go through the lecture so just for full disclosure I'm on a couple of different scientific advisory boards which I've listed here the first one is for a company called Paramus which started out of bioengineering here at Stanford and is a company involved in making sort of a 21st century device for measuring blood pressure I also advise a company called bio innovate Ireland which is also doing something similar in Ireland and then I'm on the advisory board for a company that makes a drug related to kidney disease called episode so what we know now so I think it's important to start off with some basic facts about high blood pressure and why do we care because for many years people really didn't care that much well high blood pressure affects a lot of people it affects about one third of the u.s. population and more than half of all Americans who are 65 years or older have high blood pressure so it's pretty common what is perhaps the most striking is that more than half of the individuals that have high blood pressure don't have blood pressure under control that is probably more so now than it was two years ago when the target blood pressure that we all aimed to get to was lowered based on clinical studies and based on national guideline recommendations in this lecture I'm going to show a few slides I'm gonna show results of a clinical trial just a tad bit of research data but mostly talk about general concepts but the concepts that I will talk about from a research standpoint relate to the actual number for the blood pressure target that we want to get to so this is an important point that half of all individuals with the condition aren't under control we care about this because hypertension is a major risk factor for major life-altering diseases so what would those be so we can think of the long-term sequelae of hypertension related to several different organs but I've tried to encapsulate some of the more critical ones here so high blood pressure can lead to heart disease that can be in the form of myocardial infarction or a heart attack or in the form of heart failure high blood pressure can also cause brain disease that can be in the form of carotid artery disease or in severe cases stroke and in long-term dementia has been associated with higher blood pressure high blood pressure is also famously associated with kidney disease in multiple ways and although I'm a nephrologist I'm gonna be wearing a blood pressure hat for today but just at this juncture I'll let you know that high blood pressure is both a cause of kidney disease it is an exacerbate er of existing kidney disease and it is a consequence of kidney disease so kidney disease and high blood pressure go hand-in-hand high blood pressures also can also damage the blood vessels so that can be of relevance to heart disease that can be of relevance to carotid artery disease and stroke but that can also be of relevance to what we call peripheral arterial disease which you may have heard of in Prior sessions of these this health lecture series related to disease to the blood vessels that go to the arms and the legs high blood pressure is also a critical risk factor for for disease during pregnancy so things like preeclampsia things like premature birth are related to high blood pressure so I've tried to list a number of the conditions here this is not all-encompassing but I tried to hit some of the highlights as to why we care about blood pressure and certainly there are acute consequences of high blood pressure and I didn't really cover those here but what we're talking about here are the long term risks of hypertension so there's a lot to care about so what's shown here is a graph with arterial blood pressure on the y axis and a year of worth of data spaced about a month apart on the x axis the top line is the systolic blood pressure and the bottom line is the diastolic blood pressure so that's sort of the upper and lower limit if you will of the blood pressure and the arrows refer to different time points at which something happened for this individual along the bottom and I don't know if this will show up on the video but I will try along the bottom here do we have a pointer by any chance or is that does that not translate very well in video format okay that's me I'm just gonna stick my hand over here just for a second these two terms here an electrocardiogram or EKG and LVH refers to left ventricular hypertrophy which is a thickening of the heart so it's a consequence of high blood pressure and protein or protein in the urine is a readout for kidney disease so a consequence of high blood pressure and and had measurements of a marker for kidney disease at the points in plus does anybody know who this individual is yes sorry no it's not Dick Cheney he's had a lot of heart disease but it's sorry it's not me no thanks thankfully it's not me and it's not any of you it's not Bill Clinton this is an individual that's passed away this is Franklin Delano Roosevelt this is his blood pressure and the arrows referred to various events in and around 1945 and when I say that why we care it's because people didn't care for a long time hypertension has long been known as the silent killer and is afflicted individuals throughout human history this being one of the more celebrated examples and dr. Franklin Roosevelt died of a brain aneurysm and as noted there was quote-unquote no indication of eminent danger despite the fact that this blood pressure was astronomically high with blood pressures getting as high as 200 millimeters of mercury which would somewhat send anyone to the emergency room these days and having already demonstrable consequences of high blood pressure long before the so thankfully hypertension care has improved since this time and I'd like to go through a little bit about what where we are with that hypertension care now so this is another graph or grid rather that outlines the current goal blood pressures so if there's if there's one particular slide to take away from this first part of the talk it's probably this slide so these refer to different stages of hypertension or conditions and the first column is the systolic blood pressure level and the second column is the diastolic blood pressure level this is what physicians use to categorize or phenotype patients that come to see them and so we start off with what is considered normal blood pressure which is less than 120 over 80 the second category is sort of pre hypertension this is a category that's really hard to name because it comes with a lot of baggage when one names a condition like this but that is considered to be a hundred and twenty to about a hundred and thirty over something less than 80 so a blood pressure of 125 over 75 would fit in that category the next step up is hypertension which is starting with stage 1 hypertension when the blood pressure the top number the systolic blood pressure is between 130 and 139 and the bottom diastolic blood pressure is 80 to 89 and this is an and/or table so if you have a blood pressure of 125 over 85 you would fit this category because even though your top numbers is less than 130 your bottom number is greater than 80 millimeters of mercury and that the last category is stage 2 hypertension which is when the blood pressure is greater than 140 for the systolic and or the diastolic is greater than 90 so these are the newest recommendations based on a number of different societies they are not uniformly agreed upon nor uniformly followed but they are one of more popular national guidelines and that's why I chose to show it to you here oh I forgot to describe my symbols I just realized this the cuff in the bottom right is that symbol is a sphygmomanometer that's something that is attached to all of the poem blood pressure monitors that you all have it's a cuff in a bladder and we'll go over that just a little bit but I hope that that's fading I hope that the use of these things are fading over time and I'll explain I'll explain why and I hope that the use of a SmartWatch will come into play in the in the near future yes so the question is which if either is more important systolic blood pressure or diastolic blood pressure the simplest answer that I can give you is they're both important I tend personally and every physician is different I tend to go by the systolic blood pressure more in particular just as a as a simple way of tracking things but also because it's more common than not that the two of them will track together there are cases on the periphery of the normal where the two are completely disjointed then it's a bit more of a difficult management issue but in general I follow the systolic blood pressure a bit more than I follow the diastolic blood pressure but in reality one follows both and looks at both if that helps clarify that so what this slide is this is a history slide so this is a slide of the level of target blood pressure above which is considered hypertension for different guideline recommendations over time so on the y axis is blood pressure and millimeters of mercury in blue is the systolic blood pressure goal and in orange is the diastolic blood pressure goal and on the x-axis R is a time scale from 1966 to about - now to 2017 which was the last a major guideline was put out in the United States and the points along the way represent different trials on the x-axis and the dots in the middle of the graph represent different guideline recommendations over time you can see here that the lines do move we don't have the same blood pressure goal that we did at the time of FDR or Kennedy or Lyndon Johnson we have a lower blood pressure goal now and that blood pressure just recently dipped in 2017 so the table that I showed on the prior slide of our level of what is considered controlled blood pressure that table has changed just in the last two years so 130 over 80 is going to be the number that I want you all to remember at the end of this at the end of this hour it's a next slide so how do we measure this blood pressure because it matters and it matters for it matters for long-term sequelae of hypertension so what's shown here is a slide that I have purposely not made it legible this is a slide that is taken from the guidelines this is a table in the American Heart Association and American College of Cardiology as well as several other societies that got together and put out guideline recommendations in November of 2017 and this table represents all of the things that should happen in order to prepare a patient for measuring the blood pressure so these things relate to sitting down being calm avoiding certain medications and/or habits coffee cigarettes etc prior to measuring the blood pressure and repeating that blood pressure and coming up with a number because this number as we as we covered is very important and so getting to this number the measurement should be as accurate as possible I can probably count on one hand how many of you probably have gone through blood pressure done this way as opposed to probably either how you arrived at Hoover pavilion today or how you typically would arrive at a doctor's office which is you have to park and run in and be accosted by someone at the front desk and then probably had your blood pressure measured not in a quiet room but in the hallway probably simultaneously when the thermometer was in your mouth and you were getting your pulse read and asked about your medications and saw people going down the hallway it's not it's not typically done in the manner that this that this table represents but I think we have to have a standard and this table represents what that standard is so it's important to know that blood pressure is not all that accurately measured in the large majority of cases in typical routine clinical practice which in some regards is the travesty right this is an important number this is a vital sign and yet it's not altogether measured that accurately one of the things that we did at Stanford and this paper was published about two or three days ago by one of the Stanford and medical students and colleagues of mine that represents a way of measuring blood pressure that has been introduced in recent years to to possibly level the playing field as it were so on this graph is a comparison of two measures and one of them is routine clinical blood pressure as I sort of Illustrated earlier and the other is something called a O BP so that stands for automated Acela metric blood pressure and it's not the abbreviation is not so important but the concept is probably more important the concept is that one sits in a quiet room has a cuff placed on them by a professional and then the a button is hit on the machine and that's a countdown for about five minutes so no blood pressure is taken for five then blood pressure has taken about a minute apart three times and then averaged so that doesn't require a machine but that is not typically the way blood pressure is measured in clinical practice but when you measure blood pressure this way it's important because in many clinical studies which are used to inform the clinical guidelines that we have blood pressure is measured in this standardized way so we are really comparing in reality we are comparing apples and oranges when you have a blood pressure in clinic if that blood pressure is used to dictate your care compared to what is done in a clinical trial that was used to figure out what the blood pressure targets should be so on this graph on the x-axis is an average of routine clinical blood pressure and blood pressure done sitting down and resting or AOB done with by a OBP and on the y-axis is the Delta between those two measurements so this is about two hundred two hundred and fifty measurements in various patients here at Stanford over about a year at our specialty hypertension practice and the first thing you'll notice is that at any one level of blood pressure so first patients come in with very different levels of blood pressure there are some patients that come into clinic with a blood pressure a systolic blood pressure of about 130 and there are other patients that come into clinic with the systolic blood pressure as high as 180 or 190 millimeters of mercury the second thing that's okay the second thing you'll notice is that at any one level of blood pressure the difference between a standardized automated wrested blood pressure is very different and can be very different than the routine clinical blood pressure so on average and the middle line indicates the average the routine clinical blood pressure is about 10 millimeters of mercury higher than the automated wait five minutes systolic blood pressure so that means that if your blood pressure were 125 by routine clinical measurement that on average in this study the blood pressure by an automated cuff after five minutes was about 115 millimeters of mercury but that is an average over all 200 to 250 patients for each individual patient and on this graph a doc refers to an individual patient the number could vary widely so you could have a blood pressure that was 20 30 points higher if you rest it or was exactly the same as if you did or did not rest or was 40 50 points lower if you rest it so it's not really possible to take all of routine clinical practice and just subtract 10 you have to actually measure blood pressure in a routine in a standardized automated wrested way in order to generate that wrested blood pressure to the quote/unquote level the playing field and in this study in particular when we looked at patients that were above 130 over 80 in other words they were not at a target blood pressure by national guidelines about 25 percent of those people so one in four by had a blood pressure that was lower than the target if you used arrested blood pressure or an AO BP blood pressure in other words if we relied on the routine clinical blood pressure we would be over treating about one in four patients which overtreating of blood pressure also leads it also has consequences patients will fall patients will have side effects from drugs these things matter also so consequences of a to higher blood pressure matter and consequences of to lower blood pressure also matter so one of the one of the guideline recommendations is to measure blood pressure after five minutes of rest along with some other parameters but that's probably the most important factor to be honest and that that matters for clinical care and if you look at some of those long-term sequelae that we mentioned earlier so heart attack stroke heart failure kidney disease they track a lot better with a rested blood pressure or an al BP measurement then they do with the routine clinical blood pressure for the reason that this graph illustrates that the routine clinical blood pressure is not so accurate there's a lot that's a lot that comes into that whether someone's walking down the hall whether you're talking at the same time whether you're late whether you're running in for practice or maybe you're not maybe you're completely calm and your routine clinical but pressures exactly what you're rested blood pressure would be so this really helps level the playing field and is something that is recommended by national guidelines daily activities this spikes the stresses etc versus their relaxed measurements so for the audience at home the question is how does one factor in out of office activities related to the blood pressure and I will get to that in the second part of the talk because the reality is is that it's not factored in as systematically currently as we would want but it does matter for for outcomes it matters for long-term sequelae of high blood pressure so I'll get to that in the second part of the talk if you don't mind I think I want to save the rest of the questions for then thank you though so since hypertension is a condition which is a term that I pause before I said because high blood pressure is thought of in many ways I'm calling it a condition some people call it a disease some people call it an indication but it's it's not always thought the same and it's taken care of by a lot of different professionals so I'm a kidney doctor and I take care of people with high blood pressure but you're gonna find primary care physicians Family Practice Physicians obstetric of obstetricians cardiologists nephrologist endocrinologists neurologists there's such a such a breadth of specialty specialties that have some domain that effects or is affected by high blood pressure so a lot of different doctors take care of high blood pressure and so one one approaches it differently depending on the specialty that that one's from that's just a fact and what I'd like to do right now is just approach it from the idea that this is a this is a disease in and of itself and if it's a disease in and of itself it has a cause and it has risk factors for how you'd get it and those things matter because controlling this disease as we mentioned earlier can prevent long-term sequelae of high blood pressure so the pie chart shown here refers to the general population of patients with hypertension in terms of cause so there is a sliver of patients that have what we call secondary hypertension and that term comes because the majority of patients have primary hypertension and primary hypertension has other names too probably which are much more familiar to you one is essential hypertension which i think is a horrible name because there's nothing essential about having high blood pressure or idiopathic blood pressure which is probably a more accurate term because we really don't know the cause of everybody with high blood pressure and we can guess pretty good but we don't actually do that many tests to figure out what is the cause of high blood pressure because it's so common and most of the time we can't pinpoint it so we don't spend that much time taking taking doing tests and trying to figure out the cause which is astounding if you think about it there's not very many specialties or conditions or diseases in medical practice where one doesn't bother to figure out why you have it and this one affects 1/3 of the United States population and half of everybody over 65 and we just kind of chalk it up to to just general bad luck and it's common and so part of trying to figure out what the causes are is something that will I think occupy the minds of hypertension ologists as we go forward but for the time being but 95% don't have an identifiable cause and have what we would call primary idiopathic or essential hypertension and about 5% will have a secondary or identifiable cause of hypertension so when we even though we don't know the cause of patients with hypertension we do have a sense of what what adds gasoline to the fire so what are the things that can exacerbate high blood pressure and can potentially take someone who has who needs one two or three medications and if you eliminate these exacerbating factors can bring them down in terms of the number of medications they need or in some cases can actually bring them below the target level to the point that they don't need medication or to the point that their blood pressure is normal so this is part cause but mostly the we think of these as exacerbating factors and these are the common ones so the question relates to sodium and I have dietary sodium listed here as an exacerbation factor let me address that when I when I get to that in just a moment so one of the most common causes of high blood pressure is obesity and when I say common I mean about 70 to 80 percent of patients with obesity have hypertension it is astoundingly common equally important with regard to that risk factor is weight loss to take care of that obesity helps to reduce blood pressure so this is a is a big part of what we call the diet and lifestyle measures that we employ and talk to patients about with hypertension or even pre hypertension patients that are don't have normal blood pressure but don't yet have stage 1 hypertension a second one is a lack of exercise or a sedentary lifestyle and and this is one that also the the second side the flip side of that coin is true in other words if this is identified as a factor for high blood pressure increasing exercise or decreasing a sedentary lifestyle will help to reduce the blood pressure the third of these is something that is not altogether commonly tested for but is really common in patients with severe hypertension which is obstructive sleep apnea can I get a show of hands for the for those in the audience that have heard of obstructive sleep apnea or sleep apnea or OSA great that's that that makes me I'm happy I'm happy because it's it's really important that that message gets out for those of you who haven't heard of this obstructive sleep apnea refers to the idea that one stops breathing due to an obstruction in the airway and this is the purview of both pulmonologists and sleep medicine physicians who can test for this and can treat this I should say also ears nose and throat physicians can treat this too and the worse your blood pressure the more this helps to get identified and treated so without getting too much into this one of the things that we try to do in a hypertension specialty practice is to ask about this query this and test for this if we suspect it because it really can make a difference in bringing down blood pressure more so if you have severe high blood pressure than if you are chugging along at a blood pressure of 131 over 81 where you just barely over the line it matters a lot more if your blood pressure is much higher the next point is diet which is probably the one we as hypertension physicians get asked about the most because it's one that people can most easily influence in their daily life and I've written down here high sodium diet and when I say high sodium diet there are many ways to define that in according to the United States recommended daily allowance you want to have less than two grams of sodium in the diet and this refers to sodium not sodium chloride or table salt so the numbers can sometimes be difficult to to convert but on the on the label of the nutrition label of any purchased food item it's written in milligrams for sodium so if those numbers total to less than 2,000 or less than 2300 which I've written out here that would be considered a standard to low sodium diet the average sodium diet is probably double or near triple that for the average American so it is it is a major part the way that this gets asked about in clinical practice varies widely this can be something that you may see a dietician for this can be something that physicians will ask if you add salt to your to your your cooking or to you have table salt to add to your food sometimes it's asked in the form of how often do you eat out because that's a pretty good proxy in my in in my experience as to how often you're getting sodium because food that's eaten out typically is flavored with a lot of sodium another way that we have tried to gauge sodium if we don't feel that we have a reliable history or if something's not fitting in the picture quite clearly is will do a standardized steady-state urine collection to quantify the amount of sodium in 24 hours and while this is not completely accurate all the time and probably the more data the better it does give us a little bit better window into the amount of sodium in one's diet there are a variety of studies that say that a high sodium diet can lead to worsen blood pressure there are a variety studies that say that a high sodium diet can lead to bad outcomes of hypertension so long-term sequelae of hypertension such as heart disease and kidney disease there are other studies that will actually say that sodium does not matter for a long term outcomes as the gentleman here referred to it's a hotly debated topic but some of the data that I believe you're referring to am a completely certain of the study but I believe you're referring to does take into account a number of patients that don't yet have high blood pressure so not everybody's an incident high blood pressure patient in most studies where you're talking about patients that already have high blood pressure lowering the sodium in the diet can help substantially it is not immune from the same rule that applies to everything on this list which is that it varies per person so if you have obesity and you have high blood pressure in one patient or one individual a loss of 10 kilograms will have a profound effect on blood pressure whereas another individual it might only have a small effect the same goes for exercise the same goes for obstructive sleep apnea the same goes for lowering of sodium in the diet so everybody varies and the factors that cause people to vary are part environmental and part genetic but it's important to know that most of these things in most studies have met the bar of getting into guideline practice and have met that have stood the test of time especially in patients who already have high blood pressure when you're talking about individuals that don't yet have high blood pressure and you're looking at whether these measures will prevent bad things that are related to hypertension such as heart attack stroke and kidney failure it's not so clear but in patients that already have high blood pressure the data is fairly clear the last comment I have here is on drugs so these refer to both benign and not so benign forms of drugs probably the one that I've listed here that I find the most useful to query about in clinical practice are pain medications so non-steroidal anti-inflammatory drugs or NSAIDs which include things like motrin ibuprofen Aleve Naprosyn naproxen these are medications that when taken chronically not just for a week if you have an orthopedic injury but when taken routinely and chronically can exacerbate high blood pressure and we look for these for a variety of reasons but we look for them in kidney clinic and and hypertension clinic the other things on those lists can oftentimes influence the blood pressure in the here-and-now so things like tobacco can raise your blood pressure illicit drugs such as cocaine and amphetamines can raise your blood pressure acutely nasal decongestants like sudafed can raise your blood pressure acutely so we ask about these things particularly if somebody has a very high blood pressure in clinic and you're assessing whether that is part of their routine blood pressure that they have at home and in clinic or it's just it's just at that at that particular time yes sir so the question is why would we prescribe aspirin to lower the blood pressure if aspirin is on this list of analgesics and the answer is that aspirin is an exception to that rule aspirin is an exception to the rule it has some of the side effects of non-steroidal anti-inflammatory drugs but doesn't appreciably raise the blood pressure and it has so many other saline benefits that it is something that we often recommend it is not specifically recommended to lower blood pressure though but it is at least according to guideline practice it is given to many patients who also have hypertension because it is given for conditions that are commonly associated with hypertension or are caused by hypertension such as heart attack heart failure and other cardiac abnormalities and so peripheral arterial disease carotid disease so that's why patients that take aspirin and have hypertension often often could associate the two but it is usually not given for hypertension specifically deception so tylenol is an exception to this rule narcotic medication is also an exception to this rule if you don't mind we can we can do more of the questions at home at the end but this is terrific I'm glad you guys have a lot of questions so this slide is another pie chart of a breakdown of primary do Pathak exceptional hypertension versus secondary hypertension and the first slide we had a 95% 95% to 5% ratio and here I'm showing a much larger piece of the pie associated with secondary hypertension and so what this pie chart refers to are those patients that have severe hypertension and I haven't given you the definition yet of severe hypertension but it generally refers to patients who take their medication and take several medications as many as three or four medications or more so different classes of antihypertensive drugs and they despite that still have elevated blood pressure they try to address the risk factors that we went over on the prior slide and despite that have high blood pressure they're compliant with our medication and despite that they have high blood pressure and so in this group this represents about a fifth of all patients with high blood pressure so that means 80% of patients with high blood pressure don't have severe hypertension but 20% of them do and if a third of the people in the country or a hundred million people have high blood pressure 20% of a hundred million is a big number so this is commonly encountered in clinical practice and because of the notion that they have a five-fold higher chance of having a demonstrable cause of their high blood pressure this is the population that might get special screening tests for high blood pressure why do they have high blood pressure let's see if there's a specific cause that we can target and treat rather than giving a blanket therapy that would apply to anybody with essential hybrid so that's why I put up this graph this does not apply to everybody if you walked into a clinic with a blood pressure of 135 over 85 and you were 59 years young you would probably not get a whole bevy of tests and ultrasounds and MRIs and things like that but if you have severe hypertension and you've bounced from Doctor to doctor to doctor and nothing is controlling your blood pressure and it's been years you might encounter a physician that would send a number of different tests looking for different secondary causes of high blood pressure I don't want to get into this because in the entire hypertensive population it's still only about 5% but there are lots of different causes that that come under this umbrella and so if you're if you have high blood pressure and you're getting tests done to elicit a cause of that high blood pressure your physician is probably looking for the things on this list some of these things are much more common than others some of them are extremely rare and I don't for the sake of time have time to get into all of these things but there are things that we do know that cause blood pressure that we can either identify as a specific cause or treat as a specific cause so in certain patients we will look for them those certain patients include patients with severe severe high blood pressure they also include patients that are 25 and have high blood pressure so very young and yet have high blood pressure because that's not a common age to develop high blood pressure or 85 because that's also not a common age to develop high blood pressure all of a sudden so there are different instances where we might look for high blood pressure causes and there are many more instances where we might go ahead and start treatment from the get-go so just to give you that distinction of what we know now that's part of clinical practice oh we're running out of time so I'm going to go a little bit quicker through this because this is data and the bottom line of this data is probably more important to get to so this this is a picture of the article title from an article that came out in 2015 about four years ago in the New England Journal of Medicine which is a preeminent medical journal and it's entitled a randomized trial of intensive versus standard blood pressure control and this reported on the results of a study called the Sprint study which was an acronym that referred to a systolic blood pressure intervention trial I'm I'm drilling down a bit on this particular study because this heavily influenced the current guidelines which were revised in 2017 so this was a study that involved over 9,000 individuals and the study was designed to ask one particular question at the time this study was designed the goal blood pressure was less than 140 millimeters of mercury for the systolic blood pressure and it had been known for a long time that perhaps we need a better trial to see how low we should go so maybe the global pressure should be as low as 120 millimeters of mercury so this trial had patients enroll and they flipped a coin and had patients either be in the group that used enough medication to get down to a blood pressure of 120 or less and the other group get down to 140 as was convention at the time and followed them and saw whether they developed the long-term sequelae of high blood pressure in the form of heart attack stroke death and this trial was particularly important because it involved and was enriched for cohorts of individuals that don't get in don't get enrolled in all the blood pressure trials and have been involved in smaller trials before that but this was this was meant to be the largest enrollment of her a number of different subgroups of patients including the elderly including patients with prior cardiovascular disease so patients that already had sequelae of high blood pressure or word high risk of having events from high blood pressure and also patients with chronic kidney disease and the the punchline is that the trial ended early big New York Times article made the lay press the safety monitoring board realized that the patients that had a blood pressure less than a hundred and twenty were having so many fewer events than the patients that were targeted at just under 140 that it was not ethically possible to continue the trial they had to stop and report the findings so about a quarter there was a about a 25% reduction of the risk of having a heart attack or stroke or death in the group that was less than 120 versus 140 and there were more events that are associated with low blood pressure in the group that got down to 120 as you might imagine but the overall mortality was improved if you had a lower blood pressure than if you had the higher convention at the time target and when they tried to see if there was one cohort of the patients that was really driving this result in heavily influencing the average there wasn't this referred across the board to different subgroups and every time the average fell on the side of lower is better and that's why these boxes are on the left side of that vertical bar so that heavily influenced the American Heart Association American College of Cardiology guidelines and these guidelines were put together by a team of experts including folks from here at Stanford and they asked several questions they asked what should be our blood pressure target how low should we go they asked which anti hypertensive medications should be used in particular populations and which pattern of anti hypertensive medications should be used should we start one medication and then ramped up the dose until we're at the maximum dose and only then then and only then add a the medication or should we start with a low dose of one type of medication and then add a low dose of a second type of medication if patients don't have control and then the last question is is there evidence for self-directed monitoring for better outcomes putting it another way if you check your blood pressure at home do you do better which is really the topic of the second part of the time Donna can I ask a question if we go slightly over is that is that we go slightly over is that okay would you all be ok if we went slightly okay I apologize for those of you have to get back to the game but I can assure you it's affecting me as well so so this is a flowchart that was part of those guidelines and so this is not a straight line so there are factors that matter when you're trying when your physician or your advanced practice provider or your care provider is trying to determine what blood pressure you should be at and what's the proper target and how to get there and so this all distills down into that chart that I showed earlier that if your blood pressure is less than 120 over 80 that's normal and there's nothing to do if your blood pressure is greater than 140 over 90 or stage 2 hypertension that's easy you got to start medication the rub comes in between what do you do if you're in between those areas so if you're between 120 to 130 on the top number side we consider that pre hypertension and it's not quite normal but it's less than 130 and that is the domain under which we provide a lot of guidance on diet and lifestyle measures things like controlling weight increasing exercise lowering sodium in the diet asking about risk factors that is that is the the sphere under which those things will will will still make a difference if your blood pressure is greater than 130 or even greater than 140 or 150 hundred 60 we still employ those measures but it's when it's when the blood pressure is higher we have to use medication kind of from the outset depending on how high the blood pressure so the biggest and most complicated part of this of this table or this flowchart and the most controversial part came when you had a top number that was between 130 and 139 so this is if you'll remember the the goal prior to sprint prior to that systolic intervention trial being published the goal was to get about pressure less than 140 and here we are your blood pressure is 135 what do you do do you go by that Sprint trial that just came out that was stopped early and in the New York Times or do you go by the tried-and-true convention from before that said you're less than 140 nothing to see here nothing to do here go about your day and the answer that the that the guideline committee and the writing committee settled on was that it kind of depends on how at risk you are so if you're between 130 140 then one uses a ISO squad at cardiovascular disease risk score to determine how at risk you are from consequences of high blood pressure things like heart attack and stroke and so the things that come into that equation involve age they involve other factors such as cholesterol and a risk score can be calculated by your physician in about three seconds using an app using epic you're going on the internet all of you can do it to it's very simple but if that score exceeded a certain value then it was considered prudent to start medication and if you were not at risk at all and your blood pressure was greater than a hundred and thirty then it was considered safe to employ the standard fare of diet and lifestyle changes no need for medication just yet so it's a complicated system but overall our goal is to get a blood pressure less than 130 over 80 how you do that kind of depends on how at-risk you are whether you can use diet lifestyle measure or whether you also have to use medication in some patients it's pretty simple in other patients it's a bit more controversial so the summary of the guidelines was that and this was this was in contrast to prior guidelines in Prior in Prior generations which was that there was a different number for different groups of patients if you were 85 years old you had one number if you had chronic kidney disease and diabetes you had a different number and it made it very confusing so one of the goals of the writing committee was to try to make this as simple as possible and back up what they said by as much data as they could so for the general population a goal of less than 130 over 80 I still considered that guideline recommendation that was the same if you were less than 60 or greater than 60 that was the same if you had kidney disease or didn't have kidney disease that was the same if you had diabetes or didn't have diabetes that last point is a bit controversial because this study didn't include diabetics on purpose but based on other studies which I didn't have time to get into and based on other analyses since sprint was discontinued this guideline was felt to be appropriate for patients with diabetes as well this is a quote that applies to the guidelines but wasn't part of the guidelines which is that the use of any drugs that reduce blood pressure to help protect patients from strokes or other serious events is more likely to help than giving patients no drug at all so I think this is a this is a generally a true statement certainly if your blood pressure is 115 over 75 you don't need any drugs at all but I try to go by the adage that the higher your blood pressure is the more benefit you're going to get from medication and the less likely you're going to do harm and so also the type of medication to use is probably less important than the use of medication at all and that every group probably benefits from some blood pressure control some groups may benefit from a particular type of medicine more than a different medicine but they benefit from some versus no medicine at all so while I don't have time in this hour to go over the specific types of anti hypertensive medications we got off time for that in the question period but some medicine is better than none so for the second part I wanted to discuss the future and what we know now and I've changed my symbol to a SmartWatch to reflect this so I alluded to this earlier when we talked about high blood pressure and one of the questions from the gentleman on on the left was what about all the stuff that happens at home and how the blood pressure is at home and the title of the slide is out of office blood pressure is more strongly associated with risk than routine in Clinic blood pressure and that is true so what's shown on this graph and as I populate it is the y-axis is the two-year cardiovascular risk and on the x-axis is the systolic blood pressure and this is sort of the risk for routine in Clinic blood pressure this is taken from a study from 1999 but it applies just as well now compared to daytime blood pressure that's measured with either a monitor that's affixed to you all day or measured you know routinely and periodically throughout the day versus the 24-hour average blood pressure which incorporates blood pressure from the nighttime as well but look at this last one this last dotted line is nocturnal blood pressure so this tells me that the nocturnal blood pressure the blood pressure we aren't measuring all that often now is the one that matters the most for cardiovascular risk so in terms of home and office there's really kind of four categories of hypertension that one could have so I've got a two-by-two table that we're going to fill in with boxes here and on the x-axis is going to be two camps of either normal blood pressure at home or high blood pressure at home and on the y-axis is two camps of either normal blood pressure and clinic or high blood pressure and clinic so the first box is probably the most self-explanatory it's normo tension or normal blood pressure when you're normal in clinic and normal at home you're normal all the time nothing to do and the last box on the bottom right is also probably the simplest to two to think about which is sustained hypertension so this is blood pressure that's high in clinic and high at home and when I say high at home I mean during the day at night one or both this box in the bottom left high blood pressure and clinic and normal blood pressure at home this is oftentimes referred to as white coat hypertension because patients may respond with either stress or some other identified factor and having high blood pressure in clinic but yet you know doc when I'm at home my blood pressure is totally fine that blood pressure you've got is inaccurate I'm fine at home what do I do and and so that's that box and the last box here is probably the one that's the least intuitive which is the blood pressure is normal in clinic and yet the blood pressure readings at home are quite high and this is referred to as masked hypertension so that term was first coined by dr. Pickering in 2002 but it gets about a sentence and a half in the national guidelines today yet if you measure if you measure the percentage of patients that have each of these it's about it's a little bit less than 10% of patients all tol that will have masked hypertension 8.4 percent so this data is taken from about 63,000 patients in Spain that got blood pressure may in clinic and also had a 24-hour ambulatory blood pressure monitor affixed to their upper arm to get readings during the day and at night and just generally at home what's what's shown here is the all cause mortality when you look at the the different buckets here and masked hypertension had a higher mortality risk than sustained hypertension so that means that if you're high at clinic and high at home you were better off than if you were fine in clinic and high at home which is astounding and is the least diagnosed thing because unless you're measuring blood pressure at home you would never know you would never unmask that you have masked hypertension so this is both common and consequential and currently not diagnosed that much so I I put it in this part of the talk because it's it's what we need to know going forward so how are we gonna how are we going to assess for masked hypertension so I have some pictures later on but I think one of the ways that this is going to come to fruition is with wearable technology and things like things like a SmartWatch can measure a lot of things and things that are affixed to the patient or the individual is a huge industry it's predicted to be a hundred billion dollar industry by 2024 and probably a hundred fifty billion by 2027 so whether you have a smart shirt or a SmartWatch or anywhere in between that all is considered wearables and for healthcare wearables there's really three categories that this fits into these are things that are part of just information gathering for information gathering sake the term that is used for this is called infotainment so entertainment based on information it's also going to be useful going forward for things like precision medicine which is a term that our at the medical school Dean uses a lot here when talking about the future of healthcare and also for precision trials where we can track data much more precisely for for measuring outcomes and currently there's a lot of things that we can measure by current devices we can measure dietary intake by putting me either taking a picture of a piece of food or a package a package coded number Oh or just typing in a calorie count we can measure body weight by a scale that can that can automatically bluetooth the weight to your phone and then to your doctor we can measure other vital signs you can measure temperature heart rate and rhythm Apple the Apple watch the for version for that just came out this year actually can measure a equivalent of an EKG lead and can detect atrial fibrillation as approved by the FDA which means that there's a lot more data going to physicians and researchers now than there ever was we can even measure respiratory rate and even properties of sleep through a SmartWatch we can measure activity certainly and anybody here who has a Fitbit or an Apple watch or anything in between can can measure activity we can get genetic data that can be incorporated into into the assessment of the other terms here and in the future hopefully we'll have we'll have wearable blood pressure why does this matter so why would we care we would care for the reason that I showed on the prior slide that blood pressure at home matters nocturnal blood pressure matters and yet even if we measure blood pressure at home on a piece of paper and we write it down once a day or twice a day that's a burden on the patient it's not uniformly done across all individuals some people rest before they measure their blood pressure some people don't some people take it in the morning some people take it at night some people think both some people take it at 12 o'clock some people take it two or three times and then average it some people do it for a week and then don't do it at all it's completely arbitrary the data that we get and we don't have standardized home blood pressure there is a way to measure it like in the spanish study where you can wear a cuff for 24 hours but that's certainly not going to be something that most people wear all day every day for a month and one of the questions that has come up is how often do we need to do this let's say you had a device that could measure your blood pressure let's say it was a watch that couldn't measure your blood pressure or a wrist device of some sort what does matter by a couple of different studies is that the higher frequency of blood pressure monitoring does alter both the precision and the accuracy and that's important because more precise data intuitively is not necessarily that important but more accurate data is definitely important and it's because currently the way we take care of hypertension as we go by targets and if the blood pressure device that one has is more accurate by getting more measures then you're likely to not over treat or under treat for the same reason that if you use arrested blood pressure with an AO BP device you are less likely to be inaccurate in terms of the blood pressure that matters compared to the routine clinical blood pressure so how would we do this the graph on the left is probably the most common way that most people do it they have a home blood pressure cuff which many people in the audience said that they did I suspect most of you have an upper arm cuff as opposed to a wrist cuff and you write down blood pressure or your it's Bluetooth to your phone or you type it into an iPhone or you keep a log but it's usually different from patient to patient some people bring in Excel spreadsheets with averages calculated and nice smooth graphs over months not everybody does that and it's not completely clear that that's more helpful but other people will do a 24-hour ambulatory blood pressure where your physician or your care provider gets a report such as shown on the right well we have a reading over the 24 hours and we know what percentage of the time you're over target and what percent of the time you're under target and depending on the smartness of the cuff and the engagement of the user you actually have information about what one was doing at the time that the blood pressures were being measured and so exercising walking etc and this can measure blood pressure during the day blood pressure at night etc so the device on the right is the is probably the the standard of care for measuring nocturnal blood pressure currently but kind of how did we how did we get here so the first recorded measurement of blood pressure really happened in the 1700s in a book called hemostatic s-- and soon after that a manometer was developed by the gentleman who came up with Poe cells law and then the sphygmomanometer was invented in 1881 the one that you all have now isn't that different from the one that was from then we're in need of a change in 1905 dr. korotkov coined the term for the sounds the Korat cough sounds that's important because that's what your care provider uses to measure your blood pressure if they're using a handheld device and listening with a stethoscope to get the systolic and a blood pressure the diastolic blood pressure then in the 1990s a Scilla metric home and office devices became much more common these are probably the type that you have at home if you don't have a mercury manometer or an aneroid cuff and they are often they have sort of replaced a mercury cuff for standard standard practice and they're fairly accurate but kind of what is the what is was the new wave look like if we get into how we would measure blood pressure often and during the day and at night you know we know that we need to this idea of masked hypertension has been around about 17 years in 2015 which was kind of the year of hypertension if you think about it this is the year that the Sprint trial was published this is also the year that the the US government put out a recommendation that if you have high blood pressure in clinic that it was going to reimburse for doing a 24-hour ambulatory blood pressure at home in order to formally diagnosed hypertension not to give it to a patient that already has hypertension to make sure that their blood pressure at home is accurate and doesn't have masked hypertension it was just used to kind of look at white coat hypertension and that's that's an important distinction then in 2017 these guidelines that I was referring to came out and the idea of using an ambulatory blood pressure monitor was not wholly endorsed for patients with existing hypertension but it was considered expert opinion that it's a good idea in cases where you're unsure and then last year the Center for Medicare and Medicaid Services actually asked the medical community to comment on the idea of using an ambulatory blood pressure monitor more often maybe we should be reimbursing for this maybe this is important maybe measuring blood pressure at home and diagnosing masked hypertension should matter so I'm proud to say that the Center for Medicare Medicaid Services was listening many hypertension experts around the country commented on this and provided either data or references or expert opinion that it should be considered more often and there's some current changes that have been proposed which I think are still in the works but it looks like soon enough an ambulatory blood pressure monitor may be available certainly more likely than it has in the past and so we'll have to see what happens next year this is a slide of novel blood pressure devices that are not yet on the market and I put this up just to give you guys a sense that there are companies that are working on this there are all different kinds of blood pressure devices that may be a blood pressure cuff on the finger or on the wrist or even a blood pressure without a cuff using a different form of measuring pressure and pulse wave velocity to a what the blood pressure is or using the back of an iPhone as Samsung has on the back of their iPhone there is a way to measure blood pressure or using other techniques and each of these has their pluses and minuses and some of them have been endorsed by the FDA but they're out there there are different ways of measuring blood pressure I've shown a picture here of kind of some of them there is something called the ha emraan heart guide which is actually a watch that was approved by the FDA I will stop and say that I I don't work for Omron at all and I haven't not seen their validation data but this watch is available for public purchase I wouldn't caution everybody to go out and buy one nor do I think it's going to be bought by consumers all that often but the idea that there is a watch that has a cuff as as the wristband that can measure blood pressure and that is purported to be accurate is an advancement compared to the 1881 technique that we've been using for all this time there are other blood-pressure devices the one at the top right is the only one that's actually not a cuff based blood pressure that is endorsed by the European Society of hypertension which is one of the validating bodies none of you would probably be caught dead wearing this device for more than more than a few minutes but it is a way to measure blood pressure without a cuff but you have to be at rest which is advantage and advantage for nocturnal blood pressure not an advantage for going to Trader Joe's them and and the the data on the bottom right is just a different technique which comes from the company that I helped advise and so I don't want to say any more about that at this time I think with all of these new devices it's really really important to take caution and probably five years from now there'll be way more ways of measuring blood pressure than there are now and they will all be validated and endorsed and from and be familiar to your your care provider but right now I would not say that that's the case and validation is absolutely critical what's shown here is a study out of cardiovascular medicine here at Stanford which looked at a variety of different wearables looking at heart rate and energy expenditure so how many calories are you burning or what's your heart rate and so these are things like fitbit's Apple watches a number of other different types of devices and they took about 65 patients and had them run on the treadmill they had them get their heart rate up and down measured measured energy expenditure in two different scenarios and then use the gold standard to compare and for the heart rate devices were pretty good the error rate which is shown here by the yellow bars to the left is is that you know one device is off compared to the gold standard and to the right is vice-versa but look at energy expenditure the error bars are huge this smacks of inaccuracy and the need for validation and the same is true for blood pressure in 2017 there was an app called I believe it's called instant blood pressure there was a company that is defunct now but advertised that their blood pressure device accurately measured blood pressure and it was a device that seems like voodoo now which was that one was instructed to hold the device up to the to the breastbone and wait a few minutes after you push a button on a machine and then a blood pressure would show up on that device and colleagues at Johns Hopkins decided to validate that that device and found that it was inaccurate about 80% of the time but it had had over you hadn't had thousands and thousands of downloads by that time and it took a it took a article in a major publication to to cause the the downfall of that device but not before I'm sure some patients had a purchased the application and God forbid they actually used it to to influence their care yet it was 80 percent inaccurate so validation is critical for all of these new devices so I will leave you with the idea that multiple modalities are under development there are ongoing issues with all of them the rest versus motion artifact is a it's a big one the form matters we know that patients are not going to wear something all the time if it's clunky right and how often a patient needs to actually interface with the device versus something that just passively measures your blood pressure matters a whole lot there are lots of examples of applications that can input all sorts of data to your to your device and then transmit it to your healthcare provider but if you have to be typing constantly all day you're unlikely to continue it in the long term so patient engagement matters and I can't emphasize enough how much validation matters and will improve the synergy between patients and providers provided that it's accurate so I'd like to end there was sort of what we know now and what we ought to know in the future and take any questions thank you for this I guess I'm going to start with the gentleman in the back so the question is beta blockers lower adrenaline and how do they lower adrenaline the answer is that they don't really lower adrenaline but they lower the effect of adrenaline so beta blockers and depending on the type can block the receptor which adrenaline or other hormones similar to adrenaline act and so that's how they would lower the effect of adrenaline rather than the actual level of the adrenaline itself during the day it goes up sometimes down yes how is there any guidance about how often it should be how often it can be Baroque what happens during the day I mean it's very confusing um so the question has to do with what do we do with the pattern of out of office blood pressure relative to this one number that we're supposed to we're supposed to hang our hat on and the answer is that there are guidelines on what is the average for the 24 hour that we should be following what is the average so what you know what is the equivalent risk average for the in-clinic blood pressure of 130 over 80 when you're looking and assessing at the 24 hour versus just the day time versus the nighttime so there are parameters that are the equivalent for that they're not exactly 130 over 80 so the nighttime blood pressure has to be lower than 130 over 80 the day time blood pressure most of the time also has to be a little bit lower than 130 over 80 and the in the 24 hours kind of part a part of daytime and part nighttime but there are there are equivalence and I didn't have time to get into the to those numbers but when you do a 24-hour ambulatory blood pressure monitor those equivalents are part of the report and it's reported as such and read as such and it should be interpreted as such by a care provider and in the reports that come out from the companies that that generate those reports they're its signified on there I would say that the most important thing to think about for long-term consequences is what your organs see so your organs see and average your organ see an average over time and the extremes are the things that are exception to those rules so if you have a blood pressure that is one less than 130 over 80 all of the time great it's a simple interpretation but if you have a blood pressure that's a few times during the day greater than 140 over 90 but a lot of times during the day it's less than 120 over 80 and the average is less than 130 over 80 you're you're good that that would be considered something that would be okay if you have a blood pressure that's 80 systolic blood pressure of 80 over 50 a blood pressure that's a hundred and eighty over 110 that's that's not okay so there are acute there are acute thing acute examples at the extreme ends that that matter for risk for acute events and so it is a combination of average and looking at the data but in general the average matters more than the sum of the actual numbers so we don't necessarily query by number of times greater than 145 for example it's probably more accurate to query by the average over the 24 hours and studies that have value ated risk long-term cardiovascular risk go by the means they don't go by the number of times it's less than the target out of out of the day because that you could imagine if you had all this data and an ambulatory blood pressure monitor captures data about every half an hour over a 24-hour period so that's 48 points of data people who measure blood pressure at home on their own measure it maybe two or three times at most right when when we assess the the risk it's the mean over that time period that's used it's not the percentage of the time greater than 130 over 80 often times those two things will track together but then there are exceptions to the rule so the question is if you're over 80 years old or you're hitier's young can your blood pressure be higher and do you have to take as many medicines as when you were younger so the answer is that according to the H a the American Heart Association and American College of Cardiology guidelines we still shoot for a blood pressure less than 130 over 80 by guideline recommendations but what is paramount in taking care of anybody in medicine for any condition is the individual patient so part of that refers to the maximum tolerated medications that people can take so if you have a blood pressure that has been 145 over 95 for decades because the old recommend guideline recommendations were that greater than you know let's say 139 over 89 let's just say as an example that was considered normal for years and now we're saying less than 130 over 80 and your body is used to that and then we try to shove more medicine in you and get it down to 122 with a 17 millimeter drop in blood pressure you're probably going to feel that and it is certainly not something that we do quickly if we're going to bring your blood pressure down and there are cases where patients may just not feel well and may have an adverse event from bringing their blood pressure down too much so we if we're going to bring both assure down we go slowly and in some cases if patients don't tolerate that or don't tolerate more medicine than when they're currently taking we often won't give more medicine but in some cases if there are no risk factors to be had or no events that have happened or no effects of the medications that are adverse and we just had the numbers to go by we probably would slowly try to get your blood pressure down to less than that goal there are societies other than the American Heart Association that haven't agreed with those guidelines that don't recommend bringing the blood pressure down to less than hundred thirty over 80 for elderly individuals but you know that debate will continue and each physician will adopt their own version of the guidelines and how comfortable they are with them but there are going to be physicians that are bringing that blood pressure down but there will also be some physicians that don't so it really kind of depends on the individual patient yes something for example one their 60s a certain high range of blood pressure versus lower blood pressure normal blood pressure and with the mortality differences so the question relates to sistex mortality statistics based on age and high blood pressure so ages range so are there are there age specific are there age specific guidelines yeah yes so the question it relates to age specific guidelines for age specific blood pressure targets rather more specifically so the most observational studies indicate that the for the same given blood pressure the older you are the more at risk you are and those curves evaluate blood pressures as low as 115 up to 185 so age is considered a risk factor for most cardiovascular diseases there was a time that the age mattered in terms of the blood pressure target that we would get to so it would affect therapy the newer guidelines are there's fewer there's fewer there's less of that for sure but older guidelines had a different cut off depending on age and it made it more if you take our victory group of people in their 60s with 140 over 90 versus a group in the same age range of normal blood pressure what what is a difference in mortality so within an age group how much does the blood pressure matter so right so the the older you are the more the blood pressure control probably matters I would say yeah right but there are observational data that that are based on age and based on blood pressure levels and it's it's somewhat linear that the for any different age group higher blood pressure is going to have a higher risk than a lower blood pressure it may vary you know the the extent and the magnitude of that risk will vary with age also and generally the older you are the more of a magnitude it matters so I can't give you data on the 60 to 70 age group I wouldn't say it's 50 but it's enough to keep the same target I would say yes so the question is about pulse pressure which is a a differential between the systolic and the diastolic blood pressure and yes the higher the pulse pressure that can be a sign of a variety of different conditions including alpha sclerosis but also including aortic valve disease a specific type of aortic valve disease so it can mean different things and different physicians will put more or less stock in pulse pressure I can I'm married to a cardiologist so I can I could say this safely that cardiologists look a lot more pulse pressure than us nephrologists wrote and I just confessed earlier that I look at the systolic blood pressure most of the time but it does matter for certain conditions yes yes sir so the question has to do with the structural etiology of high blood pressure so there are conditions where [Music] disease in the vessels can affect the blood pressure differently than the standard garden-variety primary essential idiopathic hypertension there's something called aortic coarctation or subclavian artery stenosis that will give a that give a different blood pressure pattern those things are less common and there are things that usually they present under specific scenarios sometimes very young patients or very old patients our elderly patients will present with conditions such as that we do tend to look for them probably not as uniformly and systematically as we should but these things come up for example when the blood pressure and the two arms is different and routinely different that will give us a clue to a disease in the vessels that are in the upper part of the body so we do look for them in specific cases we I've had patients that have said to me doc my blood pressure is always lower on the left it's 15 millimeters of mercury lower on the left what's going on and so there are certain things we do to kind of separate artifact from reality and then what tests you would do to to go from that point forward yes that's correct there are also physical things that affect the arteries to the kidneys that is a form of secondary hypertension which I didn't have time to get into detail about that can affect blood pressure there are things that can affect blood pressure the other way so baroreceptor trauma in the neck can cause low blood pressure so there are certainly structural things that affect blood pressure these things are not as common as essential garden-variety high blood pressure and so we don't look for them and everybody but there are clues that we use as to when we search for these types of structural things I hope it actually becomes important for clinical practice yes all the time the way the institutions take it and they maybe take the lowest number that you have taken you're reading says if they take it over a half hour you have many different readings it's so frustrating I don't really know that my reading is correct and how does one know it's correct tonight you never weren't mentioned the word stress doesn't stress affect your blood pressure isn't that the component that could cause your blood pressure to go high in the day and maybe the horn I mean cannot put you in a position where hours you had my high blood pressure which you shouldn't really have so the question refers to more than one blood pressure reading and what's what's important and how do you know which blood pressure is the most important and how often do you have to take it to get the most accurate result and also the effect of stress on yes so the effective stress permeates much of what of what I said so the blood pressure in clinic the one time routine clinic blood pressure is not considered as accurate as other things so what are those other things it's not as accurate as home blood pressure readings for predicting risk it's not as accurate has a rested Clinic blood pressure where you wait five minutes and then average three readings and use the average to assess risk a routine clinic blood pressure is not as is not as accurate as a 24-hour ambulatory blood pressure monitor so and the more readings you have the better the more accurate it is when you compare it to gold standard so the answer is the more data that you have probably the better in terms of what is used in clinic to gauge what should be done I think an average of rested blood pressures in clinic is probably the most accurate thing that we know or I know how to assess blood pressure and when taking blood pressures from home this is a difficult thing because people come in with very different modalities of having measured their blood pressure some people have a piece of paper with 12 readings on it you don't have time to sit there and calculate an average over this 12 one care provider would not I would not fault somebody for kind of looking at a list of blood pressures at home and getting a gestalt of what the average blood pressure is at home based on that that oftentimes is what is used in a busy clinical practice so what I'm saying is that the blood pressure does vary over the day it certainly varies with stress in some patients stress affects the blood pressure a lot more than other people but the average blood pressure I think wins the day the more readings you have the more important it is to take them all into account and the more important it is to if you if there's any discrepancy is to focus on the ones that are done at rest I assure you yes in this de Pury the time we arrested and sitting there they get to the reader and your cuffs give different readings very good so the cuffs that are used in clinic should be regularly routinely calibrated against a mercury manometer or a mercury Sigma on Honor in order to give an accurate reading at that time even though that blood pressure in five minutes may change but at that moment in time it should be giving an accurate reading and most clinics will have routinely calibrated cuffs to be used for blood pressure measurement number one number two the blood pressure certainly does vary over five minutes but taking if they're all rested blood pressures taking the average of those blood pressures is probably the most reliable thing that one can do rather than taking the lowest or the highest of those of those values third thing has to do with stress so stress affects people's blood pressure very differently if you compare a rested blood pressure versus a walking the clinic sit down and quickly take the blood pressure that blood pressure can be lower with the rest of the blood pressure it can be higher with the rest of the blood pressure on average it's slightly lower but it can be much much lower or in sometimes it can be the same or sometimes a little bit higher everybody is a little bit different but you have to assess in larger populations which of those types of measurements are the ones that are better associated and more closely associated with events that matter so cardiovascular risk for cardiovascular events and so the average wins the day rested a blood pressure wins the day and if you have home readings kind of taking a gestalt of those home readings is probably more accurate than simply relying on the run in quickly sit down be stressed routine clinic blood pressure from a call all assuming a calibrated cuff if the cuff is not calibrated everything I just said doesn't matter the cuff has to be calibrated and you don't trust uncalibrated readings for any of the above so you if you have a home cuff and you trust your clinic doctor I would bring your home cuff to clinic to have it calibrated where you can measure blood pressure in one arm with your cuff and the clinic blood pressure device on the other arm and then flip them and do the both and if both of them are 10 millimeters of mercury or less it's probably accurate yes so you measure you measure home on the right and clinic on the left and then flip it so home on the left and clinic on the right and if both of those comparisons are are close enough then that I would consider a calibrated cuff if you don't have an inherent trust in your care providers blood pressure cuff then I would bring that up with your care provider because that one should be well calibrated so the question is are they accurate over a period of time since I don't have a good biophysics degree and I don't work first Euler Packard I'm I I'm probably the worst person to ask about the scylla metric devices and their accuracy over time the ones we've had in clinic we've had for a long period of time so I'm assuming that they they stay accurate for a long period of time yes yes so two questions given importance that you brought out for the measurement of blood pressure devices and their quality of devices seem to vary quite a bit you know do you have recommendation or is there a source where you can go for finding out the you know accurate devices yes the same thing a second thing is like doctors have this different kind of rapid pressure medication can you sort of we just have very confusing you know yes can you say anything about I can so I'll adjust the two questions separately the first one has to do with what device should one use at home because accuracy matters and the second question has to do with which classify into hypertensive medications should I use because it might matter so in terms of the different cuffs they have at home there are several brands in which mm the majority of the cuffs that are sold by that company are validated when I say validated there are three there are three governing bodies that really do validation there's one in particular that I go by simply because I know their website address and I can look and see and they have a link to the blood pressure journal in which they published their validated readings so that's the European Society of hypertension it's called the esh / IP - protocol but there are there's a call for a number of different agencies to get together and come up with a standardized way of validating blood pressure so some of the brands that my patients have and some of the brands that show up on these validated lists imran is a standard is a standard company ything z' is another standard company Welch Alan is another standard company Philips is another standard company I would say probably Omron devices are probably some of the more popular ones that are sold if you're going with an with a home device I would get an upper arm device rather than a wrist device and the reason I say that is because there are more upper arm devices that are validated than wrist devices but most arm run devices are validated and they publish their validation data so I have tended to trust there's some companies including Omron and Whiting's have something in their device that allows it to be Bluetooth connected to your phone so there's an app on your phone and that that depending on your provider can transmit that data to your provider and at Stanford that's possible and so it makes it more convenient to have that data transmitted so you don't have to log it and if you're really interested the you know the European Society of hypertension you SH - IP protocol and I forget what I think it's international protocol - is the is a standard that was developed in 2010 and they have a website and they have a listing of all the devices whether it's wrist whether it's upper arm a link to the paper the range of blood pressure that it was validated over the age group in which was validate over how many patients it was validated over the company the serial not the serial number but the the catalog number of the device etc so most Armour on devices are validated most ything devices are validated and so a popular brand has likely gone to the trouble of getting validated because there's a market pressure to to do that and so that's what I would use and then if you have any questions I would calibrate it against a your physicians device the second question has to do with different types of medications so there's a bit of a longer answer but there are many different types of anti hypertensive medications and they're named based on their mechanism of action and there's an alphabetical term an ABCD which is very helpful so we go by it so the a refers to two types of medications that work slightly differently but are work in a related way one are called ACE inhibitors or angiotensin converting enzyme inhibitors the other a are angiotensin receptor blockers and so they they inhibit the reen in angiotensin system that is one tried in true class of medications the second the B stands for beta blockers the C stands for calcium channel blockers and the D stands for diuretics or putting it simply medicines that make you pee more and get rid of salt in the urine so that you lower the salt in you and so you lowers your blood pressure those are the four classes of medications the a the C and the D are considered first-line so not the beta blockers so when I say first-line medication I mean patient with no other medical and has high blood pressure and it's high enough that you got to take a medication it's a potpourri of choices and there's no right answer as to which medication is necessary for one patient that's why I started with that adage that it's better to treat the blood pressure with something than nothing some people will certainly respond better to a angiotensin converting enzyme inhibitor versus a calcium channel blocker and people will have a variety of responses just like some people will respond better to salt or to obstructive sleep apnoea therapy or exercise or weight loss but we don't do tests to gauge how much people will respond to a particular medication so it has not come to clinical fruition that somebody has a genetic score that says they're gonna have lower the blood pressure the most if they take an angiotensin receptor blocker or they have the clinical criteria that says that that medication will work better for them for lowering their blood pressure so this is often done in an in an empiric fashion so a physician or care provider will use one of these three classes of medications as a first-line medication and then depending on side effects will gauge whether to and response will gauge whether to go up on that medication or move to a second class and began using that medication there are some patients that have high blood pressure but also have other conditions so a good example is someone who's had a myocardial infarction or a heart attack beta blockers are considered a medication to give patients after they've had a heart attack to prevent a second heart attack and so beta blockers also lower blood pressure so it's a perfect kill two birds with one stone indication so even though beta blockers are not considered a first-line medication for blood pressure they are a perfectly reasonable medically first-line but blood pressure agent for patients that have those conditions or patients that have heart failure or patients that have an arrhythmia a beta blocker is a very nice first choice for that type of patient there are other conditions conversely where angiotensin converting enzyme inhibitor or ancient has a receptor blocker which is an a would be a good first line supervisor D chronic kidney disease would be that example condition or diabetes would be a very good example condition there are certain there are certain classes of medications that are better based on your rest and racial ethnic background so african-americans will tend to respond much better to a diuretic versus a calcium channel blocker or an angiotensin converting enzyme inhibitor and so it depends on the patient and other conditions but there is a certain amount of empiricism to the picking of medications and also to the pattern which is used thereafter in terms of in terms of ramp up move over or keep low dose synergy across multiple medications I would say that the latter strategy is probably more commonly employed now because our population is aging and side effects play a much larger role in how we treat patients and so a lower dose of more medications is probably safer from avoiding side effects than a high dose of one medication before moving on to the second medication and so that that specific strategy and which medication to use is kind of an open question which is why I didn't want to spend I already ran half an hour over I didn't want to spend too much time on that particular question but there are conditions very clearly that one medication is the first choice for but if there's no clear can no clear reason and a a C or a D is kind of pick your poison no way of knowing how good is this proposition in some sense I've seen that they sometimes say particularly the D category it can also cause blood pressure to become very low sometimes so they say oh should you take while medication let's not unite zero 20mg let's go to 40 mg versus let's stay with 20 mg but go to this D category of medication No so in part in part yes because there's no right answer the proof is in the pudding the proof is in the response that patients have so lowering the blood pressure to target is more important than the choice of medication if there's no if there's nothing driving the choice of medication if there's something driving the choice of medication a comorbid condition like heart disease or a comorbid condition like chronic kidney disease yes then there are clear choices for a first line and even a second line agent but if there's nothing driving that choice then it's then it's the it's the response and it is a reactive strategy you know we don't sort of send a test saying ACE inhibitor sensitive check will give you an ACE inhibitor so a lot of times it will depend on the comfort level of the care provider as to what they're going to choose first and so there is some empiricism that that comes into play but there are rules that we go by either in terms of so a great example is if you have if you have a condition where on clinical exam or from history one realizes that swelling is a is a is a part of the it's a part of what a patient has and they have high blood pressure will oftentimes reach for a D or a diuretic because we're anticipating that that's going to help lower the blood volume and lower the blood pressure more than one of the other agents but that's not always the case and we don't always have clues that help us sometimes there are blood tests that patients have that will drive the choice of medications sometimes you can kill two birds with one stone sometimes people have conditions with contraindicate certain medications so for example a thiazide diuretic is a very effective blood pressure agent given by a nephrologist left and right if you had a severe history of gout arthritis or severe history of hyponatremia most physicians or most care providers would pause before starting a thiazide diuretic so there would be contraindications to certain medications too so it depends on the patient and depends on the other conditions that they have but you know if all of that is off the table in spire empiricism yes yes and how that relates to a home so the question has to do with coffee so in this case I'm referring to caffeine decaffeinated coffee doesn't matter but caffeine can raise your blood pressure and so it was one clinical trial as an example there was one clinical trial that I was a part of where we had to we had to make sure that patients had a certain blood pressure or below in order to safely enter the clinical trial because the medication they were getting while beneficial for one condition tended to raise the blood pressure so we had to make sure that they were under a certain target in order to qualify for the medication and patients would come in and if their blood pressure was above a certain level and you asked them did you just have a cup of coffee it's morning time you probably got up very early and drove all the way to Stanford and needed something as pick-me-up in the car did you have coffee before you got here and they say yes we would tend to wait a little while and then retake the blood pressure and it would be perfectly fine so I use that example that that anecdote has a way of saying that caffeine can raise blood pressure acutely so it affects one's interpretation of the reading that you have but if you were to take 24-hour a great reading is over a population and say whether caffeine was a risk for hypertension or not I would say it's not a big risk for hypertension but if you were to look at the individual reading and what decision is being made on an individual reading caffeine doesn't matter so that's why it's an important part of the history because certainly if your blood pressure is less than target and you just had a cup of coffee and you show up with a blood that's too high and you never drink coffee you just happen to drink it because you came to Stanford and Starbucks was the only thing open on the way you probably don't want to get a whole new medication that you're gonna take every day for the rest of your life so so it does it does matter but I'd say it matters more in the short term some of the risks that I talked about there were things that matter in the long term modify their monitoring routine in order to not skew their readings take a blood pressure before they have the cup of coffee maybe maybe that's in the morning when just get up before you have to cough right then you have the coffee if you want to monitor again during the day to get three readings in a day or two how long do you want to wait I would say an hour and a half to two hours after the cup of coffee is perfectly fine yeah if you're drinking coffee frequently throughout the day I often use that as a surrogate to start asking about sleep apnea though because if somebody has fatigued from not getting a good night's sleep because they have obstructive sleep apnea and they feel that they need caffeine throughout the day to stay awake there's a reason behind all of that caffeine and so we have diagnosed obstructive sleep apnea based on a history of excessive caffeine intake so that's something that I asked about if it's purely just habitual and it's not something that that one's likely to change or and there's any reason to change then then I would just measure it sort of not immediately after the cup of coffee in order to yeah the question is is there any amount that's considered excessive I don't know the answer to that question certainly a lot of coffee has other side effects for other things and so I imagine that there is an amount that is considered excessive but I I probably can't tell you exactly what that is was this baby aspirin affect the blood pressure not appreciably no correct it is not a problem yes sir yes so the question is what is the correlation between heart disease and high blood pressure what's the chicken and what's the egg so we is nephron and again I can make fun of cardiologist because my wife is is one of them high blood pressure is a cause of heart disease heart disease is not often a cause of high blood pressure in fact severe heart failure usually presents with a lower blood pressure yes yes severe heart failure does high blood pressure can lead to heart disease usually not the other way around the exception to that would be the rare case of coarctation of the aorta which is not technically heart disease but it's close enough anatomically where one would present with hypertension in the upper extremities and lower blood pressure in the lower extremities that's not really a heart disease per se but it's the closest thing to it where the heart would be the cause of the high blood pressure otherwise generally no the heart is not the cause of high blood pressure it's the effect yes sir question is about smoking so smoking is a risk factor for atherosclerosis which can affect your risk for hypertension correct yeah so blood pressure is the Ohm's law of medicine right it's the pressure is the flow times the resistance so things that increase your systemic vascular resistance are going to increase their systemic blood pressure for the same level of cardiac output yes ma'am so the question is about low blood pressure and heart disease so the specific type of heart disease that can be associated with a lower blood pressure is systolic heart failure usually so interestingly the hypertension guidelines don't actually say what is considered too low a blood pressure usually what is considered too low is when one has evidence of a lack of blood flow to vital organs when the blood pressure is below that level so that would be considered low blood pressure so an example of that would be if you're dizzy had a blood pressure of 105 systolic and a systolic pressure of 105 millimeters of mercury if that makes somebody dizzy and that's probably too low for that individual if somebody is perfectly asymptomatic at a blood pressure of 105 millimeters of mercury I would not say that that's too low there are also patients by extension that have a blood pressure or systolic blood pressure of 90 91 millimeters of mercury who have no symptoms whatsoever and that's perfectly okay for them there are patients that have a low blood pressure and have evidence of lack of blood flow to vital organs so dizziness would be an example of a low cerebral or brain blood flow profusion there are patients that have elements of kidney disease when their blood pressure is too low and we measure that on standard blood tests and would probably devise the blood pressure to not be so low if that were the case and then there are other organs that can be measured in other ways to measure that and there are generally causes of low blood pressure specifically if it's more symptomatic but we usually don't chase low blood pressure unless it's symptomatic or just the number is way too low and I would say any number less than a systolic over less than 90 would be something that is out of the norm but there I don't want you to leave here thinking that if your systolic blood pressure is 95 millimeters of mercury that there's something wrong it depends on the individual and and certainly the more asymptomatic the less likelihood that that patient that that blood pressure is too low but the more symptomatic it the more likely it is that that blood pressure is too low yes sir I'm not a cardiologist I don't talk about pots right so the question was about pulse rate and most of these devices will measure the pulse rate also and the pulse has it's a whole several sets of lectures that we didn't have time to get into but in general as a nephrologist I don't pay that much attention to the bolts rate but it matters for certain things just nothing I had the time to talk about today okay thank you guys very much appreciate

Channel: Stanford Health Care

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Keywords: Stanford, Stanford Hospital, Bay Area Healthcare, Medicine, Medical Science, Stanford Health Care, heart disease, health, wellness, chronic illness, hypertension, Stanford Health Library, kidneys, heart, cardiac, stroke

Id: zsEIxBjTKEs

Length: 116min 11sec (6971 seconds)

Published: Thu Jun 20 2019