hypertension: The 2017 Clinical Guidelines

A visual guide to the new hypertension guidelines: https://www.medpagetoday.com/cardiology/hypertension/69399
In writing: http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults
I don’t watch television news, so I always hear about these things from patients first. “What do you think of the new hypertension guidelines?”

“Haven’t heard about them yet, so I don’t know.” Seems pretty embarrassing really, doesn’t it? Shouldn’t I be alerted as a doctor before it hits the news?

First of all, these guidelines are NOT JNC 9.

What is JNC 9, you ask?

One of the messy complications of medicine for people in the US and in the world, is that there is not ONE set of guidelines. There are multiple sets of guidelines. Take mammograms, for example. The US Preventative Task Force* said that the evidence in their review could not differentiate between yearly and every other year mammograms. They said you could do it every other year. The American Cancer Society and the Susan Koman Foundation yapped and had different guidelines, do it yearly. So as a physician I have to not only pay attention to the guidelines but know who is putting them out. The radiologists wanted yearly mammograms too, surprise, surprise.

And do you think some of it is driven by money? Well, it’s the US.

JNC 8 is the Eighth Joint National Committee and put out guidelines in 2014. Their job is to review all of the big hypertension studies since JNC 7 and put out new guidelines. JNC 8 took over a year, was multidisciplinary, and the final document was 400+ pages.

They said that if a patient was over 60, their blood pressure should be taken standing up, and the goal was under 150/90. Under 60, sitting, goal under 140/90. Normal is 120/70 and below.

Then there are pages and pages of recommendations about which medicines to use and in special circumstances, that is: diabetes, kidney failure, heart disease, atrial fibrillation, etc, etc.

The cardiologists promptly started yelling about how JNC 8 is wrong and they put out a huge study saying that people have less heart attacks if their blood pressure is 125/80 or below.

But… the heart is not the only organ in the body. My patients are 77% over age 50 and 48% over 65. Once a person hits 80, their blood pressure may drop when they stand up. Most do. And low blood pressure, well, it’s bad for the over 80 crowd to get poor blood flow to the brain or to the kidneys or to faint and break things. That is why JNC 8 is multidisciplinary: because we need geriatrics and psychiatry and ortho and family medicine to be part of the guidelines.

So these NEW and IMPROVED guidelines. Well, who is putting them out? American Heart Association, American College of Cardiology, and a bunch of other mostly heart related organizations. And they are comparing it to JNC 7, not JNC 8. JNC 8 is being ignored. This document is a mere 192 pages, with the “short” version being 112 pages.

It says that blood pressure 130/80 to 140/90 is stage I hypertension, not prehypertension, and that we should treat it with lifestyle changes. Drugs are still to be recommended at anything over 140/90, though honestly, I start with lifestyle there too. Over 180/120 is now “hypertensive crisis”, consult your doctor immediately. 140-180/90-120 is stage II hypertension.

How will this change my practice? I am still thinking about the new guidelines and who has skin in the game. The AAFP (American Academy of Family Practice) put out a link to the guidelines and then a cautious comment to the effect of “We are studying how we should respond to this.”

Before this came out, I would tell people the JNC 8 goals. I do stand the people over 60 up, most of the time. I also tell people that the cardiologists want their blood pressure lower. And then that the cardiologists mostly ignore hypertension and cholesterol guidelines anyhow. If I follow the guidelines and then the patient sees a cardiologist, the cardiologist usually changes something. Guidelines be damned.

It comes down partly to a patient’s goal. I have people come in and say, “I don’t want to die of dementia!!” I see that as an opening. “What DO you want to die from?” People have different ideals. Some say, “I don’t want to die!” but then many do think about it. Sometimes this changes their ideas about what they want treated and what they don’t want treated.

Not everyone’s blood pressure drops in their 80s. Some people develop hypertension in their 90s. I tell them. They say, “I’m not taking a drug!”

I reply, “Let’s talk about strokes.”

They usually are not afraid of sudden death, but they don’t want the disability of a stroke. Many choose medicine after all.

One of the issues with guidelines is complexity. I could spend 20 minutes with a patient just talking about hypertension guidelines and choices of drugs and side effects and why they should be on an ace inhibitor or ARB if they have diabetes…. and there are guidelines for EVERYTHING. Sometimes conferences feel like all the specialists yelling: only half of diabetics are controlled, only one third of hypertensives are controlled, family doctors aren’t screening for urinary incontinence enough, osteoporosis, lung cancer, stop smoking! And then what my patient really needs is to talk about their adult child, in jail for addiction, and how frightened they are about overdose and the grandchild and the future…..

JNC-8 flowchart: http://www.nmhs.net/documents/27JNC8HTNGuidelinesBookBooklet.pdf
JNC-8: https://jamanetwork.com/journals/jama/fullarticle/1791497
*lots of guidelines: https://www.uspreventiveservicestaskforce.org/

Causes of Death in the United States in 2012

When I first started doing annual physicals I sat down and looked at the top causes of death and then organized the counseling part of the physical around them: starting with heart disease and working down the list. I think of the annual physical as my opportunity to “MOM” patients and say “STOP DRINKING LIKE A FISH OR YOU GONNA DIE EARLY,” though perhaps with a little more diplomacy. Sometimes without much diplomacy at all.

The top ten causes of death in the United States in 2012 were heart disease, cancer, chronic lower respiratory diseases, stroke, unintentional injuries, Alzheimer’s disease, diabetes, influenza and pneumonia, kidney disease, and suicide.

http://www.cdc.gov/nchs/data/databriefs/db168.htm#which_population

This is 2,543,279 deaths in 2012.

Let’s take the causes one by one.

Heart disease: This is number one. 599,711 deaths. 23.6% of total deaths all ages both sexes in the US in 2012. So that is where I start when I do the counseling part of a physical.

Let’s review heart disease risk factors:
hypertension
high cholesterol
family history
diabetes
kidney failure
lack of exercise
tobacco
alcohol
smoking other things…
illegal drugs
stress
obeisity
As you might guess, this part of the discussion can use up a lot of the visit….

Cancer: All the cancer deaths together are 22.9% of the 2012 total.
We can screen for a few cancers: lung cancer is now the number one killer for both sexes. A chest xray is useless for screening. There is a certain population of current or former heavy smokers where a screening CT is useful. No, I do not recommend a “screening full body CT”, that is crap. Yes, lung cancers do get picked up randomly when we do a chest film for some other reason.
We can screen for breast cancer, colon cancers, look for skin cancers, the prostate cancer screen is a counseling nightmare and I don’t recommend a PSA but will do one if the person wants and other cancers pretty much we have to watch for symptoms….stop smoking, ok? That’s what causes 70% of the lung cancer and breast cancer used to be number one in women but smoking made lung cancer beat it out….
If you want details about any screening test, go to the US Preventative Task Force site:
http://www.uspreventiveservicestaskforce.org/Page/Name/tools-and-resources-for-better-preventive-care

Chronic lower respiratory diseases at 5.6%: ok, smoking again. Emphysema and chronic obstructive pulmonary disease, AKA COPD. Asthma too. This article is fascinating, that third generation children of smokers in a polluted part of California are worse and have inherited genetic modifications than third generation children of non-smokers who live in a less polluted part of California. Lovely. I grew up in a two pack a day camel household and no wonder my lungs are tricky.

Stroke, also called CVA, cerebrovascular accident, at 5.1% and then there are TIAs, transient ischemic accidents, the stroke warning symptom.

What are the risk factors for stroke?
Oh, smoking of course
hypertension
high cholesterol
stress
lack of exercise
obeisity
blocked carotid arteries
blood clots
atrial fibrillation

Unintentional injuries at 5.3%, also known as accidents.

Deaths from prescription medicines taken correctly outstripped deaths by MVAs, motor vehicle accidents and guns in 2007. The CDC declared an epidemic of overdose deaths, but it’s just starting to creep into newspapers and public consciousness.

Here: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm

The unintentional injury counseling list includes:
wear your seatbelt
don’t drive inebriated
don’t get in the car with inebriated drivers
check your smoke alarms
in the elderly, decrease fall risk. don’t stack stuff on the stairs.
wear a helmet if you bicycle motorcycle ATV rollarblade ski or invent some new way of getting on the Darwin list. Base jump, for example.
don’t take a lot of controlled prescription medicines or combine them with each other or combine them with alcohol: opiates with benzodiazepines with alcohol with ambien or sonata with barbituates and hello, the drug dealer is not your friend and tells lies: they are cutting the methamphetamines here with tricyclic antidepressants and barbituates and my long term cocaine addict patient was getting methamphetamines with benzodiazepines when he was paying for cocaine. Really.

Alzheimer’s at 3%

This is moving up the list. Fast. Everyone dies of something. Alzheimer’s patients live an average of seven years from diagnosis….And the recent article about Human Growth Hormone transmitting not only prions but Alzheimer’s is really interesting, implies an infectious cause.

Here: http://www.nature.com/news/autopsies-reveal-signs-of-alzheimer-s-in-growth-hormone-patients-1.18331

That was HGH from cadavers. I still would not take HGH made in a lab for “anti-aging” either. Nope, nope, nope.

We don’t know how to prevent Alzheimer’s but that is not the only cause of dementia and we’re still naming different kinds. Very frequently a brain CT or MRI says “decreased white matter” or “small vessel disease”, so there is a contribution from all of the heart and stroke risk factors that can do bad things to the brain with the top ones being: tobacco, alcohol, hypertension, high cholesterol, stress, lack of exercise, diabetes, illegal drugs, and so forth. Keep your brain active and busy.

Diabetes at 2.9%
Ok, it can make you more likely to have a heart attack. Also the biggest cause of blindness in US adults and the biggest cause of lower limb, yes, foot or leg amputation and the biggest cause of kidney failure in adults. Also if your legs are numb from uncontrolled diabetes, you don’t feel injuries and are less able to heal infections. And if blood sugar is high, there are lots of bacteria and especially staph and strep that LIKE high sugar.

influenza and pneumonia at 2.1%

Get Your Flu Shot. Really. And if you are 65 or older or you have tricky lungs or you have a tricky heart, get the pneumovax shot. The pneumovax protects against pneumococcal pneumonia ONLY, not all the colds or influenza or hemophilus influenza. And get your Tdap, because that stands for Tetnus, Diptheria, acellular Pertussis. Pertussis is whooping cough. It’s back. We’ve had three outbreaks in our county in five years. It kills babies under six months. They don’t whoop, they just stop breathing, apnea. Other people whoop, but even with antibiotics, they can cough for MONTHS. The flu shot usually gives 80% protection by two weeks after the shot. Only 80%, people say? Well, are you perfect?

Kidney disease at 1.8%

Causes: kidneys get worse as we age, for one thing.
diabetes
supplements and drugs: kidney failure is on the rise! Everything that we absorb and metabolize is metabolized by either the liver or the kidneys. Liver function can be perfect at age 100: that is, if it has not been trashed by alcohol, hepatitis B or C, drugs, supplements, mushrooms, whatever. Kidney function usually drops by age 80 and I am there calculating the function before I choose an antibiotic because you have to use lower doses in the over 80 crowd and the early kidney failure crowd. If you take ANY PILLS you should have a yearly test of your kidneys and liver function.
infection can hurt kidneys
inherited disorders

Suicide at 1.6%
40,600 deaths in the United States in 2013

Risk Factors http://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html

Family history of suicide
Family history of child maltreatment
Previous suicide attempt(s)
History of mental disorders, particularly clinical depression
History of alcohol and substance abuse
Feelings of hopelessness
Impulsive or aggressive tendencies
Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma)
Local epidemics of suicide
Isolation, a feeling of being cut off from other people
Barriers to accessing mental health treatment
Loss (relational, social, work, or financial)
Physical illness
Easy access to lethal methods
Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts

And for those who want in depth information, 15 leading causes of death by state:
http://www.cdc.gov/nchs/nvss/mortality/lcwk9.htm