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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Controlling hypertension
Recognition does not assure appropriate intervention
Author answers: Definition of elevated blood pressure and pulse.
No more 5-day blood pressure checks please
Overcoming inertia
A bit of a wake-up call
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William M. Tierney, Indianapolis, IN, USA Professor of Medicine
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Dr. Blum makes several important points, and I agree with all of them. He implies that "tinkering" with a patient's blood pressure could be disadvantageous to the patient and his or her cardiovascular risk. He further states that residents (and I would extend this to many practicing physicians) often use samples when adjusting blood pressure, and these samples usually contain one or more drugs that are almost never those indicated in the first couple of steps in the JNC-VII stepped care protocol. (See: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003 May 21;289(19):2560-72.) The whole reason pharmaceutical companies provide samples is to get physicians used to prescribing them. No major drug company markets thiazide diuretics and few market the cheaper generic beta-blockers, the two drugs the JNC guidelines suggest in steps one and two. The drug detail persons also use the samples as a way of gaining access to physicians for their detailing activities. For these reasons, our practice (in which this study took place) outlawed the use of samples three years ago. If the motive of the drug companies for providing samples is to contribute to the care of patients who cannot afford medications, then let them give generic drugs (or even better, funds) to the clinic pharmacy. Some drug companies have such programs for support of drug therapy for indigent patients, and I applaud them for that. Most, however, use samples to manipulate physician decision-making away from established evidence-based, cost-effective guidelines. Dr. Blum also states that making adjustments in antihypertensive therapy takes time, especially time spent educating patients. I agree, and it is what we are paid to do. But the time commitment need not be onerous. If one sticks to the established JNC stepped care protocols, one can create patient education materials for the common drugs and special comorbid conditions (such as diabetes) that could eliminate much of the verbal instructions. In reality, such written instructions would be more useful (for literate patients, at least) then a one-time verbal didactic session, where much would be forgotten. Finally, one can schedule a follow -up visit in 1-2 weeks with a nurse who can take the patient's blood pressure, ask questions about how the patient is taking the medication and drug side-effects, and enhance the patient's adherence to the medication. Competing interests: The study described in this article was funded by Bristol-Myers Squibb. |
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Alan M Blum, MD, Tuscaloosa Professor and Endowed Chair in Family Medcine
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I applaud the authors' hard work in demonstrating the natural history of the single initial blood pressure reading. Their results are sobering indeed. However, in my experience as a faculty member in a heavily inpatient- oriented family medicine residency program, I have found residents only too eager to tinker pharmacologically with single elevated blood pressure readings recorded on an outpatient visit. The deeper problem as I see it is that all too many residents do not hesitate to provide a few weeks' supply of pills from the medication sample closet (albeit with charitable intentions). Some of these are combination drugs, and many are the newest and most costly products. Stepped therapy starting with a diuretic is underutilized. Nor do residents routinely recheck the readings obtained by ancillary personnel. Patient education, too, often goes by the wayside. I believe that only a relative handful of patients truly understands the concept of blood pressure, and teaching this is a skill. Residents, faculty, professional societies, pharmaceutical companies, and the mass media alike could all be doing a far better job in educating patients about lifestyle changes, as well as in motivating patients to be well. Discussions of the relative advantages and disadvantages of the countless pharmacological regimens for treating hypertension consume a disporportionate amount of the time we spend considering ways to reduce the morbidity from heart disease and stroke in individual patients and in communities as a whole. Competing interests: None declared |
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William M. Tierney, Indianapolis, IN USA Chancellor's Professor of Medicine, Indiana University School of Medicine
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Brian Crownover asked how we defined "elevated blood pressure and pulse." We did not, because recent evidence suggests that cardiovascular risk is higher with higher blood pressure across its entire physiologic range. The recent recommendations to keep systolic blood pressure less than 130 among patients with diabetes also reflects this notion. So we analyzed systolic blood pressure (and diastolic blood pressure and heart rate) as continuous parameters. How then did we come up with the excess risk associated with 10mmHg higher blood pressure? We simply used the hazard ratios generated by the proportional hazard models, which gives the risk for each 1mmHg. For example, in Table 3 of our article, the hazard ratio for systolic blood pressure in our model for first myocardial infarction was 1.010. That means every 1mmHg higher systolic blood pressure, regardless of the pressure and holding all other variables unchanged, would increase the risk of having a myocardial infarction by 1%. We simply multiplied that by 10 to get the 10% excess risk associated with a 10mmHg rise in systolic blood pressure. Competing interests: The study described in this work was funded by a grant from Bristol-Myers Squibb |
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Brian K. Crownover, Offutt AFB NE USA Training Instructor, Offutt AFB/University of Nebraska Medical Center Family Medicine Residency
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To the authors: thank you! As a faculty member who reviews a never ending supply of resident charts, I see progress notes frequently reflect inaction on single elevated blood pressures. Often the physician is unwilling to "bite the bullet" and make a medication adjustment without multiple readings. 5-day blood pressure checks are ordered instead, despite having prior visits in the chart that document other "single" elevated blood pressures. I am grateful that primary care based research now describes the prognostic value of an isolated set of abnormal vital signs. Justification to appropriately modify cardiovascular risk with single visit data is welcome. Kudos. Can you clarify one point? How did you define elevated blood pressure and pulse? Were the 10 mmHg and 10 bpm elevations applied to an upper limit of normal of 130 mmHg and 100 bpm? Sincerely, Brian Crownover, MAJ, USAF, MC, FAAFP Family Medicine Residency, Offutt AFB NE Competing interests: None declared |
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William M. Tierney, Indianapolis, IN, USA Chancellor's Professor of Medicine, Indiana University School of Medicine
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I wholeheartedly agree with Dr. Green and admit that before completing this study I, too, tended to overlook individual blood pressure readings. My patients often say "I ran in from the parking lot" or "I'm in pain today" or "I didn't take my medicine this morning." And I believed them and believed that this might transiently increase their otherwise controlled blood pressure. This study stemmed from a request from a drug company, Bristol-Myers Squibb, to model the effects of blood pressure on vascular outcomes to help them decide how many patients they needed for a prospective study for a new drug. They suggested I use a single blood pressure measurement to assess risk, and I said, "No way that it will be predictive of long-term vascular outcomes. Blood pressure readings vary too much from moment to moment in a given patient." This is what we are taught and I believed. So I was quite surprised when the first blood pressure record in 1993 (done by regular clinic personnel with regular equipment) was so consistently predictive of so many bad outcomes an average of more than 5 years down the road. And I must admit that it has changed the way that I care for my own primary care patients. I no longer ignore single blood pressure readings but usually adjust patients' medications up, or add another medication, if the blood pressure is elevated, especially among patients with diabetes (which is almost half of my practice). I must admit that if the blood pressure reading is borderline, I will peek at other prior readings or maybe bring the patient back for another reading. But I am now much more aggressive with my treatment in response to single elevated readings. I think other primary care physicians should be, too. Competing interests: I received grant funding from Bristol-Myers Squibb to perform the research reported in this study. |
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Lee A Green, Ann Arbor, MI, USA Associate Professor, Univerisity of Michigan
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At first glance this paper only confirms what we already know: that systolic hypertension, particularly in an aging population, is a powerful predictor of the outcomes we would like to prevent among our patients. However, this paper should help shake us out of our clinical inertia. We family physicians have long done just what the authors mention: minimize or excuse those elevated readings, and take no action. These data, gathered in practices like many of ours and using ordinary clinical measurements like the ones we make, show us clearly the consequences of our inertia. We are reluctant, understandably, to push more drugs and be aggressive in treating hypertension, but strokes, heart attacks, and heart failure are patient outcomes that matter. Not every patient will find aggressive treatment a good fit for their needs and values, but every patient should make that decision knowing the evidence and knowing how it applies to them. Competing interests: None declared |
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