The pressures of high blood pressure

I want to talk a little bit about high blood pressure and particularly this idea of it perhaps we should be more aggressive in treating high blood pressure and that you know maybe we need to think about lower goals for high blood pressure I am gonna use some audience polling so if you have a cell phone if you'd like to participate basically put in this number and then put in the text randal staff 5 9 3 it doesn't need to be it's case insensitive so it can be either upper or lower case for that portion of my name I did just want to say that I have no financial conflicts I do want to point out that I was a member of this working group that Ian mentioned as well as a co-investigator in this clinical trial called sprint which I'll be talking with you about so just to kind of go over what I'm gonna cover first of all I want to get across this idea that high blood pressure is a really potent risk factor for heart disease and stroke aside from cigarette smoking which has become uncommon particularly in the bay area of California high blood pressure is the greatest risk for having these things happen as we age the Sprint study which stands for systolic blood pressure intervention trial was a landmark study which really showed that lower goals for blood pressure had enormous benefits I want to talk about these recent guidelines that I was helped develop and particularly this idea that we should be more intensive about how we treat high blood pressure particularly for those people who are at higher risk of having a stroke or heart attack sometime in the future I do want to get across this idea that we need to take on a very comprehensive approach to high blood pressure it's not just about medications although a lot of people a lot of doctors focus on that but just as important are all these non drug strategies including changing or health behaviors so that we benefit both blood pressure as well as other areas of chronic disease prevention and then finally I want to kind of bring us up to a global level and really think about a very broad approach to chronic disease prevention it shouldn't just focus on high blood pressure it shouldn't just focus on heart disease and stroke but there are so many things we can do to improve our health across the board whether you're talking about heart disease or cancer or even preserving cognitive function so I want to start out with a case this is kind of the traditional medical approach it's the one that I used yesterday when I was talking at Highland Hospital up in Oakland so here's a 65 year old professor he's overweight he has high blood pressure and some high cholesterol and he comes in to see me for a blood pressure check he's known about his high blood pressure for 11 years now and is on two different kinds of medication for his blood pressure at his last visit the time before he's coming in his blood pressure was 142 over 88 you know according to the old guidelines maybe not so bad he has home blood pressures that are a bit lower than that which is completely typical and he's also taking a drug for his cholesterol called The Tortoise statin as well as aspirin as a preventive strategy and at this visit his blood pressure is almost the same and we also know from lab testing that he has a slightly high total cholesterol and a slightly low good cholesterol or HDL so here's some polling so again if you want to get out your cell phones and put in that number and then the the text randal staff 593 so the question I have for you is up until this last year in November of 17 we were going under a set of guidelines that were generally called the Joint National Commission eight report or J and C eight so for this guy that we're talking about here the 65 year old professor what would be the goal what what is it that we wanted him to do was it getting him below systolic blood pressure the top number of 160 or was it all the way down to getting him below a blood pressure of 120 so I'd like you to participate and let's see where this goes and there is a just a little bit of delay depending on how quick the the the signal is in here but yeah this is great so as almost as almost always happens there's lots of diversity of responses I will tell you that actually the first person who put in a response of less than 150 that's the correct answer so according to these guidelines that had had been in place from 2014 through 2017 the idea is that this person really didn't need to get his blood pressure anything lower than 150 so I'm gonna ask almost the same question and note that I've been tricky here in reversing the the order of the blood pressures but according to these new guidelines which came out in November how low should we treat this person's blood pressure should it be 160 should it be the 150 that we just talked about or should it be something lower I mean again there's a little bit of delay as this occurs but okay we're gonna wait for one more in the B column yeah so the proper answer is B I knew we'd get there if I if I waited long enough and of course now that I've said it I'm sure that there's gonna be even more more B's so for this guy the 65 year old professor these guidelines suggest that his blood pressure should be one less than 130 in terms of that top number that says the log blood pressure so that's quite a change going from 150 to 130 and that's caused a lot of reaction you know kind of how certain are we about this or how much should we trust these guidelines because they keep changing wildly from 130 to 150 I want to talk about all those things but before that I kind of wanted to ask this question even a third way which is if this is your father or for some of us here maybe ourselves what sort of goal would we want to have for ourselves and you know I know that this is some ways is a little bit of a harder question but it kind of gets to this issue of these guidelines are just guidelines and I think of them as rules of thumb that we should follow where appropriate but they're not necessarily appropriate for every single person and some of the information you have about your father or yourself might lead you to be either more aggressive more intensive or less intensive so I can see here very clearly that because we're thinking about ourselves or a family member we've decided to be more intensive and in some ways that's a completely reasonable response to both the evidence out there and these guidelines I am actually very gratified that these upper levels you know most people thought that that was probably too high and that lower blood pressures were needed so first of all just to back up I've made a lot of assumptions about kind of knowing some of these things and I want to just make sure that we you know define things so high blood pressure what is it you know essentially it's flow through the body's arteries at a higher than normal pressure so we need pressure for our blood to flow our heart creates that pressure and that that pressure is maintained as the blood flows out from our heart to the rest of the body whether it's our brain or our muscles or our kidneys we need that pressure but there's a certain range of pressure that seems to be normal and high blood pressure is when our bodies are pushing the blood harder than they need to systolic blood pressure as I said before it's the top number it represents the blood pressure when our heart is contracting when there's the greatest push of having the blood flow forward and at the same time diastolic blood pressure this is essentially the blood pressure at its minimum when the heart is relaxed in between the contractions of the heart and so blood pressure in fact is always going up and down up and down with each cycle of the the heart contracting and so when we say you know 130 over 80 we're really talking about the blood pressure at two different points in time one at the peak of contraction the other at rest and blood pressures generally measured in millimeters of mercury so what's wrong with having blood pressure that's too high so high blood pressure among other things helps the formation of cholesterol deposits in the arteries this process of atherosclerosis and you can see in this little diagram here that what we're talking about is damage to the lining of the artery with this cholesterol being deposited right in that wall of the artery with the potential for some in catastrophic happening in this case showing this Lester all deposit bursting open and causing a clot if that occurs in the brain that's a stroke if it occurs in the heart or in one of the arteries serving the heart with oxygen that's a heart attack so high blood pressure increases the risk of heart attacks of heart failure where the heart no longer can pump the blood effectively of strokes and kidney disease these are the kind of main problems with high blood pressure now the risk of those things happening increases dramatically when we start talking about very high blood pressures in you know for instance 170 over a hundred and ten the increase in risk or the likelihood of having one of those bad things happening is still there with more mild increases of blood pressure but in some ways it's only a small increase in risk for instance that goes from having a blood pressure of 130 up to a blood pressure of 135 but because high blood pressure is so common particularly in the United States and affects so many different people that even that relatively small difference in risk that we see in the kind of the range of 130 to 135 even that small risk gets magnified to become thousands of people so I want to ask you another question now that we've kind of defined what high blood pressure is what proportion of adult women have high blood pressure and we're using this 130 over 80 as the definition of what's too high so is it 10 to 19 percent or is it all the way up at 50 to 59 percent what do you think so adult women what percentage of them have high blood pressure well you guys are amazing you're actually doing better than the internal medicine residents at Highland Hospital well okay now you're not quite doing so well but most people underestimate how common high blood pressure is actually in women it's about 43 percent of women having high blood pressure and many of you got the right answers that was great I did want to point out that as we went from thinking about 140 over 90 as the definition of high blood pressure and went down to 130 we did add extra people here but we added the most people down in the younger ages and you can see here there's this dramatic increase in blood pressure and high blood pressure as people age so once you get up into your 60s and 70s you know we're talking about 70 to 80 percent of the population having high blood pressure and of course as we age as a nation this simply raises the fraction of the population that's living with high blood pressure if we look at men really a very similar story with a little bit higher blood pressure particularly at older and younger ages with this addition of new people defined as having high blood pressure because of this new new definition so this is a really common issue and again even small differences in risk might not necessarily be hugely advantageous or detrimental to an individual but we when we magnify this in terms of thinking about you know nearly a hundred million people having high blood pressure in the United States this translates into thousands of people who in some sense are having these events like heart attacks and strokes that are preventable so I just very briefly wanted to touch on these old guidelines and in some sense I consider this kind of ancient history and it was amazing at the lecture I gave a couple weeks ago to students they didn't really know about these thankfully they knew about the new guidelines but these old guidelines essentially said we're gonna treat everybody to 140 overnight you want their blood pressures to be below that but if one's relatively low-risk and over the age of 60 we can relax and treat to this goal of 150 as we as we talked about earlier and there were multiple problems with these guidelines this started out as a federal process but the federal government withdrew its support of the process it essentially decided we're not gonna do any more guideline development we're gonna leave this to professional organizations to do so what started out as a federal process actually became this private kind of committee and there wasn't consensus the committee actually continued to debate many of these things even as the guideline was being published and so much was this problem but actually this subgroup of five researchers decided we disagree so strongly with these guidelines we're gonna publish a rebuttal so this is really unprecedented to have a guideline that's supposed to be consensus where a significant number of the members of the committee say we're not going along with us and so they published this kind of minority report one of the problems as I see it with the approach that was taken is there was this idea that we have to focus on the very highest quality evidence out there we have to look back and look only at clinical trials and we have to look at those clinical trials that we define is very high quality now in some ways that makes perfect sense but what happened in this case is virtually all of the research that had been done before the year 2000 was thrown out and what was left were very high quality studies but kind of peculiar studies in other ways and this really caused a lot of surprise and dismay from clinicians researchers and especially patients you know if I was seeing a doctor and last week he was telling me you know 150 is good enough and you know they're telling me 150 is good enough they'd been telling me for years that it has to be below 140 so this is a real deviation from kind of what people expected and I know many physicians who basically said I don't believe this I'm just not gonna pay attention to it and I think that if we're thinking about how to guide clinical practice that's a horrible situation where we essentially have knowledgeable well respected physicians opting out following a guideline and unfortunately some of the same thinking I think has made its way into recent guidelines published by the American College of Physicians and the American Academy of Family Practice so if we look at what's happened over time to blood pressure treatment and guidelines what we see is between 1977 and 19 and 9 2001 you kind of had this pattern of more and more willingness to treat blood pressure more intensively and this was really a nice pattern in some sense but when we have these guidelines here that are off that trend it really creates this issue of well what's really going on and it was sort of in that setting that we thought about well should we develop new guidelines so one thing I think is important to recognize is if you look at populations you take the population United States and this is a sub sample from the federal government and you look at the relationship between blood pressure here going from about 115 all the way up to 180 and you look at the risk of heart disease death there's this very regular pattern and these are logarithmic which means that a particular interval on that graph means a doubling of the risk so you have these very regular patterns all the way down to the lowest mortality being associated with very low blood pressures but part of the problem is that we can't necessarily apply this kind of information about populations to the decisions we make about individual patients and the two problems are first of all that people may differ in ways other than their blood pressure so we might have someone here and they're doing a whole lot of different things compared to somebody here and they may actually be genetically different as well and then the other problem is that we would love to be able to take this person and kind of move them down this line and get them to end up here but doing that may be very difficult and could actually cause harm to the person so in some ways this is very compelling in terms of kind of what's the best blood pressure to have but it doesn't necessarily withstand sort of scrutiny and there are some problems if we were to try to apply this kind of information to our treatment decisions so in some sense what's the alternative and the alternative is to do a clinical trial because during that clinical trial you're randomizing people to end up with different blood pressures and you're also able to very carefully keep track of both the benefits and the potential harms that might occur with blood pressure treatment so this clinical trial really set out to answer this question is intensive blood pressure treatment better than standard treatment and what they did was to take a little more than 9,000 people and randomize them basically on the basis of chance you ended up either get intensive treatment or standard treatment and equal sizes equal number of people randomized into each of those groups I was very happy to be part of the Stanford sprint site we they're another hundred or so around the country we recruited almost 200 participants from the areas around Stanford and I do want to just have a shout out to my colleague Lehnsherr Thao who is the kind of the leader of the Stanford site so this is what happened to people's blood pressure you know they came in with the same blood pressure they were randomized and then we had to treat them differently so that one group ended up just under 140 systolic blood pressure whereas the other group we were trying for 120 and we came pretty close to that okay this difference this fact that there's this huge gap between these two lines is really important because if we're gonna make conclusions about what blood pressure is better which one is associated with the most benefits and the least harms we need these people to be treated differently and so we achieve that so thinking about the results it was very interesting it kind of ended my work on the study early because this trial was stopped Midway a group got together and looked at the results up until 2015 and they basically said the intensive group is doing so much better than we don't think this trial should continue we already have the answer to the question and at that point it was found that there was a 25% reduction in heart disease and stroke and surprisingly a fairly large difference in mortality and total mortality not just mortality from heart attacks but everything that people could potentially die from one really important finding was this benefit of intensive treatment seemed to apply across the board and in particular those patients who are older seem to have even more benefit than those that were younger this is a relatively old population you know it's just the the average age is just under seventy and there were a bunch of people 75 and higher so this really showed that for a population in that age range it really made very little sense to sort of be even less aggressive or to somehow kind of relaxed our standards once you got to the age of 60 and overall there was no difference between the two groups intensive and standard in terms of serious adverse events and that has been one of our fears one potential outcome would have been yes people did better they had fewer heart attacks but they also had these other bad things happening to them they fell down they had other sorts of events they developed kidney failure they developed strokes because of low blood pressure that didn't happen it was really mostly about having these benefits associated with intensive treatment and this is just kind of the the way the scientists look at this over time you're starting here and you have these two groups and this is the number of strokes and and heart attacks and what you can see is that about one year these start to diverge and they remain different throughout the study in fact getting larger as more time went on you can see this exact pattern with total mortality as well a little bit longer time for the difference to develop which actually makes perfect sense but you have increasing gap developing between standard treatment where people were more likely to die and intensive treatment where they there were fewer deaths so in the setting of some discomfort with these older 2014 JNC guidelines and this new information from Sprint that defines sort of the rationale for putting together a group of people to really look carefully at guidelines for blood pressure and in fact this group kind of started even before the Sprint trial findings were were available and I was one of the the members of this group so what were some of the big changes that we came up with so first of all we define normal blood pressure as less than 120 over 80 and basically said that using medications which could potentially cause some side effects we want to use medications to get people down to at least under 130 over 80 particularly for those people at higher risk of having a heart disease and stroke and I'll get to that idea of who's at higher risk in just a moment there's a broader definition of who constitutes that higher risk group and as I've been implying no relaxation of our goals once people reach the age of 60 and in despite these changes one constant is that for younger low-risk patients 140 over 90 continues to be the the goal we're striving for now for so long you know if we go back into the 90s and the 2000s 140 over 90 we sort of agreed upon as the goal and what we're talking about with these new guidelines is 140 over 90 still applies to about two-thirds of the people with high blood pressure but there's one third of the blood pressure that one third of the population with high blood pressure that really should be treated more aggressively and here's just a kind of the definitions of normal and hypertension or high blood pressure and this implies I think correctly that you know people with a blood pressure above 120 over 80 don't necessarily have normal blood pressures and it is strange to sort of think well we're living in a country where about half of the population or even more than half the population doesn't have normal blood pressures and I think this just indicates sort of how far we've gone in creating a society and a set of normal behaviors they're essentially unhealthy if you can think about our physical activity level our diets the way we sleep the way we're exposed to the stress in my mind it's not too surprising that many of us are above that normal level I very briefly wanted to get across this idea that 120 over 80 and lower is still optimal okay but the idea is that we have the greatest benefit going from 140 to 130 and we can reliably use medications to do that knowing that whatever potential problems there are with side effects from those medications they're vastly outweighed by the benefits from preventing heart attacks and strokes when we get down to lower blood pressures even though this is optimal we're only having small gains as we go down in this region here for people at higher risk it continues to be worthwhile to use medications to get down below 130 but for people at lower risk there's more ambiguity the benefits are small and the potential for causing harm with the medications just makes us in an ambiguous situation so in all cases using changes in lifestyle to get down lower is always a good thing so it's not necessarily that you know we should stop at 129 or stop at 139 but that at least in terms of the use of drugs those are where we're going to meditations and I'll get back to sort of what we can do on that lifestyle part because I think that's really where a lot of the attention should be focused at this point so who's at higher risk so if somebody has disease in their arteries whether it's the brain of the legs or the heart they should be treated more aggressively because we know they're at inherently higher risk including people who you know have had a heart attack had bypass surgery or had a stroke or mini stroke what's new is this idea that even people who don't have known disease in their arteries may have risk factors they place them at high enough risk that we should also treat that group of people more intensively and we can use these risk prediction formulas and they're available online they're very easy to use and and I think quite useful we can calculate essentially what's my risk based on my risk factors of having a stroke or heart attack in the next 10 years and if that risk turns out to be greater than 10 percent then probably I should be treated more intensively and everybody else doesn't need to be treated that intensively they're defined as being lower risk so we're kind of in the situation where Sprint caused this issue it's important to note that the guidelines don't suggest going down as low as the Sprint study indicated was beneficial so this was 1:20 we're sort of at a guideline of 1:30 I wanted to just to briefly go through these because I'm quickly running out of time there are a lot of good medications and we need to be probably more aggressive about physicians prescribing medications for high blood pressure and patients taking those side effects can be limiting however and so it's one of those things we have to do this with caution but there are numerous other strategies and I think physicians need to be thinking about these strategies as treatments for blood pressure not just as good advice but actually as a treatment and just as I write a prescription for a medication I write a prescription for weight loss for physical activity and for diet to try to make sure that the patient knows exactly what the instructions are just like that prescription bottle has pretty detailed description of instructions of how to take the medication so weight loss incredibly important even if you can't lose very much weight losing even a few percentages percentage points of weight can be enormous ly beneficial both for high blood pressure and for other risk factors a healthy diet particularly a plant predominant diet is really being strongly recommended so a diet that's high in fruit vegetables and whole grains one thing that's new in the guidelines is this idea that we should encourage people to eat more of some foods and high potassium is associated with better outcomes fewer strokes fewer heart attacks lower blood pressure and we should have people consume more foods that are rich in potassium and these are mostly fruits vegetables and legumes beans we also need to continue to focus on dietary sodium because the United States is up at about 3,600 milligrams per day and even six ounces of pretzels is about half of what we should be consuming in a single day so this is an area where societally we've just gone in the wrong direction physical activity I think we all know the benefits of aerobic physical activity what's new in these guidelines is sort of saying well strength training and types of other training can be very beneficial for high blood pressure including things like yoga Pilates core training and we shouldn't just be focusing on aerobic activity alone reduced alcohol the guidelines at from many groups women should be no more than one drink per day men no more than two and these are standard drinks so it's a 12 ounce bottle of regular beer not of the high octane IPA and then just in terms of other recommendations I think it's really important that health behavior change remain a very central strategy we do need to use medications more aggressively particularly getting people beyond just taking one blood pressure medicine but we also need to properly measure blood pressure including having patients measure their blood pressure at home more frequently and we need to sort of start using different ways of managing blood pressure so not just doctor's office but telehealth communicating with people in their homes and also using other people besides physicians to provide a lot of the care and a lot of the decision-making around high blood pressure and so I just wanted to end with this idea that we really need a broad prevention approach and many of these health behaviors that I've very briefly mentioned not only reduce blood pressure and reduce the risk of a heart attack or stroke but they have all these other benefits including reducing the risk of cancer preserving bone health trying to reduce cognitive decline as we age and even for younger people fertility issues so I think we need to provoke asan this this broad approach to prevention high blood pressure is a really important part of it but it's not the only thing so I'd encourage you to think again about what health behaviors you can make yes these are very difficult issues it's not like watering the law it really takes a whole process to be able to be successful initiating health behavior change and in some ways even more difficult to maintain that health behavior change over time but given the downside of not doing it I feel like even that even though it's hard work it's hard work that's very much worth it and I was going to do this but I think I'll just very quickly and by basically saying 130 over 80 for high-risk people no relaxation after the age of 60 we need to think about this idea that those people who can benefit the most from having their blood pressure treated should be treated more intensively and then finally as I ended just a few moments ago recognition that health behavior change impacts not just high blood pressure but this whole range of other things and many of those things are actually inherently kind of more valuable to us thinking about all the ways we want to function particularly all the ways we want to function as we get older so thank you very much and although I've gone over by a little bit I think we have time for a couple questions here yeah the side effects are taking drugs to reduce your blood pressure could you just add a little bit because it seems like some people in the profession talked a lot about that as being a detriment you know so I think it's one of those things it's important to recognize that essentially we're using these chemicals to disrupt the normal function of our bodies you know in some ways one could even think of them as kind of poisoning the system now in some ways they're interfering with a system that's gone awry that our body should be able to function at lower blood pressures and still have blood get to our brain and the reason that doesn't happen is we've gained weight we don't use our hearts nearly as much with physical activity you know we are under stress and underslept so we're in this situation where things are going wrong and we almost have to knock down some of these systems to restore at least some balance but doing that causes side effects and just that process of interfering with the way our bodies regulate blood pressure has some almost predictable problems so people feeling a little bit dizzy particularly if they jump up from bed issues around sexual function are relatively common with all blood pressure medicines so we have to take into account those problems and that's why I'm such a believer in the health behavior change because those changes that form of treatment really doesn't have that downside but you're absolutely right we need to be cautious about how we use these medications we also have to be you know in some sense keep trying because people may have a side effect of one type of medication but not another what's clear to me is this takes a lot of work and probably takes so much work that we really don't have the capacity of doctor's visits to be able to deal with us and so I'm a big believer that many of these tasks don't need to be done by physicians but we can have other people in a kind of a team approach focus on high blood pressure how about right here high blood pressure and lack of Erdem indeed do you have any comments on that so the question was relationship between lack of vitamin D and high blood pressure so clearly that is the case the sort of I think there's been an extent to which it's probably been over-emphasised because the difference in blood pressure is relatively small but there are lots of reasons why we should be having normal vitamin D levels particularly for our bones so I think this is an area where there are lots of reasons to pay attention to vitamin D blood pressure is a relatively small part of that but you know it's it's again in a big picture it's important to try to to look at all these things simultaneously yeah yeah I mean unfortunately it's relatively rare for me to see somebody in the clinic and not be able to identify some reason why their blood pressure's high because relatively few Americans are doing all the right things when it comes to those health behaviors how about right here space so one question is I guess as you are in your 90s or entering 90 you feel higher should that question one continue with higher and what what about the I know it's not uncommon for seniors to have I have for example very high systolic yes it goes crazy with likes pressures issues but not often is the diastolic high and I believe that apparently the diet the diastolic has a factor in in the physicians handling and someone that's very erratic and I guess pretty much as the senior I forgotten my third question but thank you but basically how can a physician I've remembered it how can a physician help you if what numbers will they take if you are prone to these ridiculous ridiculous high systolic often and well how could they find a normal basis yes thank you very much there are a bunch of questions packed into there so let me let me at least start with the easy one so blood pressure varies enormous ly throughout the day and in fact if you think about it that's exactly what we want blood pressure to do it needs to be responsive to changes whether it's sitting up or going from lying down to standing up it has to be responsive to us moving because greater blood pressure is needed when we're physically active so with blood pressure varying all over the place during the course of the day one blood pressure is never enough to sort of provide a basis for thinking about these issues in these guidelines and in fact in this sprint study we are very careful not only to let people rest and relax before we took their blood pressures we took three separate blood pressures because blood pressure varies enough even on a minute-to-minute basis that we needed to average things so one message is don't react just to that one really high blood pressure what's much more important is what it's averaging over time the other thing is that we used to think that that high blood pressure in the most elderly which generally occurs because the arteries become stiffer over time particularly in the very elderly we used to think that was kind of normal we now know that it's not normal and that it is associated with the the same increased risk of heart attack and stroke and in general there's been a movement towards paying more attention to the systolic blood pressure not necessarily forgetting that the diastolic blood pressure is is there but if we look at you know a guideline that says 120 over 80 is normal most of the people who are above that level are gonna be above that level with a systolic blood pressure relatively few people are gonna have a systolic blood pressure below 120 and diastolic blood pressure above 80 so both kind of from the the mechanics of how blood pressure works as well is just kind of how people's blood pressure pans out we really I think it's best to pay more attention to this stuff systolic blood pressure and you know a blood pressure a systolic blood pressure that's a hundred and eighty time in in time again that's a problem and yet there are people whose blood pressure goes from 180 to 110 very rapidly and we are kind of stuck in that situation and that's a situation where we kind of have to think beyond the guidelines and it may be that we tolerate a little bit higher blood pressure because we can't have that person walking around with a blood pressure of 90 and have the the potential for fainting on the other hand there are plenty of young people who are walking around with a saw systolic blood pressure below 90 and they're doing perfectly well now one could argue that as they age in our society their blood pressure is gonna go up as well how about one more question okay great well thank you thank you for the insights and awareness my question is how do you come up what is the best way for me to estimate my number I get a reading in the morning right after I wake up I'm a medication I take a pill in the morning and I'm one in the afternoon I take my readings before taking the medication the morning is below you know 120 over 80 by noon is about 128 130 over you know a little bit over 80 but when I come back from work its 145 over 90 so what is my number am i healthy am i risk so you're pointing out an area where there's been a huge amount of debate you know kind of what should we do when blood pressure varies so much so the first answer is taking it a lot it doesn't necessarily need to be five times a day every day of the week for three months and I certainly have lots of engineers who bring in data like this what my doctor said are you an engineer but my approach is basically to say you know I want to see a record of what your blood pressure has been four or five times a week with you taking your blood pressure at different times now some of those blood pressures if you've just gotten out of work had a stressful day had a stressful commute home I probably weighed you know at least 30 minutes relaxed before I took the blood pressure but even then blood pressure tends to peak very early in the morning like 5 to 6 a.m. goes down and then after about noon starts coming back up again so there's no real easy answer for this one of the things that people debate about is well if I'm getting stressed out during the day is that a blood pressure I should pay it - and clearly if it's an unusual stressor if it's you know particularly coming in to see the doctor I tend to kind of discount that a bit on the other hand if stress is a normal part of every single workday then I think we have to pay attention to that we have to think about perhaps treating blood pressure down to a lower level knowing that blood pressure first thing in the morning actually maybe on the lowest side hopefully not so low that you start to feel light-headed does that help with the question it's a difficult one yes thank you but the point is if I'm taking my blood pressure when I'm at rest this is not my normal stage throughout the day I'm always constantly you know under under stress so is that meaningful if I take it you know during the plenty of rest and I do my numbers isn't that fake because that's not what you really are during the day so yes and no I mean I think that's the kind of that's the place of debate here you know one would never for instance have somebody run across the room and run back and then take their blood pressure because blood pressure is supposed to go up when were physically active so if we think about stress the same way then we would make the same conclusion we really need that kind of maximal rest to get the true blood pressure okay but thank you arguments that you know if stresses and every minute occurrence for you we probably do need to factor that in I've really enjoyed talking with you thanks [Applause] [Music]

Channel: Stanford

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Id: KqD3_W5Pn9g

Length: 51min 50sec (3110 seconds)

Published: Sun Jun 03 2018