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Our Blood Pressure Philosophy

In this ‘ philosophy ‘ series, I’ll share our approach to managing blood pressure. Our philosophy is based on recent research, clinical experience, patient outcomes, professional guidelines from the US, Europe, Canada, and Australia, and input from world experts in hypertension.

We don’t base our clinical philosophy on professional societies that are influenced by the pharmaceutical industry or research studies that track surrogate endpoints instead of actual disease complications.

We disagree with the FDA’s stance that surrogate endpoints are necessary for the most common chronic diseases found in the US. If a patient has high blood pressure and a medication is to be prescribed, then that medication should prove in a randomized trial (RCT) that those on the treatment arm had better overall clinical outcomes, such as fewer heart attacks, strokes, kidney disease, etc.

The Wiki article on surrogate endpoints provides a more robust overview of when it makes sense to use a surrogate marker as an appropriate measure of a specific treatment’s effect versus an actual clinical endpoint.

Complications From Elevated Blood Pressure

High blood pressure can cause major problems in certain individuals:

  • Stroke
  • Heart attack
  • Aortic dissection
  • Kidney disease
  • Erectile dysfunction
  • Peripheral vascular disease

However, just because someone has high blood pressure doesn’t mean that they will develop these problems. It’s fair to say that most people with high blood pressure will develop problems.

Measuring Blood Pressure

The best way to measure it is to get multiple readings throughout the day. An ambulatory blood pressure monitor will auto-inflate every 30 minutes and obtain an accurate read. This average would be a good estimate of your blood pressure level.

An alternative option is measuring your blood pressure using 3 readings spaced out in 15-minute intervals after being seated in an upright position without your legs crossed and your arm’s cuff at the level of the heart, without talking.

Lower Is Not Better

Current blood pressure guidelines generally follow the lower-is-better philosophy. Perhaps that will someday be proven true, but for now, it’s not the case.

If someone has only occasionally high blood pressure, starting on blood pressure-lowering medication can cause low readings, which can activate the RAS system inappropriately. A low BP will then cause a rebound elevated pressure response with many highs and lows, leaving the patient feeling quite exhausted.

When to Start Medication

After all lifestyle options have been attempted and maximized, medication may be necessary for those who are at risk of developing the complications mentioned above.

Medications aren’t for life. They can be stopped if something changes. In fact, many elderly patients who lose weight later in life end up having to stop their medications due to excessively low readings or orthostatic hypotension.

When to Continue Monitoring

We have a lot of patients with hypertension anxiety – in which they constantly measure their blood pressure, leading to anxiety, which elevates their BP, which causes them to want to check even more.

We will have our patients measure their blood pressure for a few days after starting treatment and at random intervals. That’s it.

Goal of Therapy

Once we begin a lifestyle intervention or medication, the goal of therapy is to lower the blood pressure to a level the patient can tolerate. We use lifestyle interventions and/or medications that don’t cause harm or are impossible to tolerate.

Markers for Early Signs of Problems From Hypertension

We look at a few markers to determine whether someone is already developing early problems from elevated pressures inside the body’s circulatory system.

Our blood pressure philosophy is that if we see any of these markers, we can assume that this person may already have some very early damage. Beginning treatment would greatly improve their overall health, prevent further damage, and hopefully reverse some of the existing damage.

1. Atherosclerosis

The main driver for developing arterial plaque (atherosclerosis) is elevated blood pressure, followed by high cholesterol and, of course, smoking.

2. Retinopathy

Optometrists and ophthalmologists can see early signs of arterial disease in the retina, which is an early sign of excess high pressure in the arterial system.

3. Cerebrovascular Disease

Some CTs and MRIs might show early signs of brain changes that could indicate cerebrovascular disease, possibly due to hypertension.

4. Peripheral Vascular Disease

We can measure peripheral pressures, especially in the legs, and also perform Doppler studies to show signs of early damage to the arteries in the legs.

5. Proteinuria

Microalbuminuria is a test that can help us find very early signs of protein making it through the kidney and spilling into the urine. Like the other markers above, such an early sign would be an important reason to consider starting to treat elevated blood pressure.

6. Cardiac Dysfunction

An echocardiogram can tell us if the heart is pumping and filling properly.

7. Elevated Uric Acid

Elevated uric acid can cause hypertension and might also be an early sign of what’s to come. If we can lower it through diet, great. If not, we’d consider treatment with medication.

8. Inflammation

Any signs of inflammation would be concerning due to potential damage to the endothelium, which can lead to plaque buildup and vessel dysfunction.

9. Early Hearing Loss

Those who lose their hearing early in life and have high blood pressure might be at risk of other neurovascular complications.

Risk Factors for Initiating Blood Pressure Management

The following risk factors are considered together to give a clear picture of the patient’s overall risk of developing disease from elevated blood pressure.

There is no one-single-answer that fits every person; it’s necessary to review each person’s case individually.

1. Family History

Family history of heart attack, stroke, kidney disease, blindness, early hearing loss, etc, would all be considered.

2. TIA History

Anyone with a history of a Transient Ischemic Attack would be at high risk of future complications from elevated arterial pressures.

3. Cognitive Decline

If cognitive capacity is decreased, including memory, attention, executive function, language, reasoning, learning, problem-solving, perception, and processing speed, then we’d consider that person to be at high risk. Unless, of course, they are simply not stimulated, aren’t exercising, or have a poor diet.

4. Kidney Disease

According to hypertension philosophy, any decrease in function in glomerular filtration rate (GFR) or rising Cystatin C would be of concern.

5. Atherosclerosis

Early atherosclerotic can be of concern in some patients, whether from a CT angiogram, x-ray, or a CAC.

6. Poor Exercise Capacity

Elevated pressure can decrease cardiac function, which should show up on a stress echo, but not everyone will have done such a test. Poor exercise capacity would be a risk factor we’d consider.

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