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/

The uninhabitable spaces between us

still in my heart

why are you there?

you have sold me out
more than once
disappeared when I was sick
returning when I was better
long after I stopped being contagious
and noted when the news caught up
with what I’d been saying about opiates

she’s been talking about this
you say to others
I realize that you did not believe me
until the news agreed

another with words
“If you make me choose
I will choose her.”

I think “you just did.”
do you hear?
that is a threat
to shut me down
to shut me up
to shut me out

you won’t choose
I choose now
I walk away from your threat

another tells me to visit
and talk about her dead

she has refused to talk about
my dead
to me
for five years

how can she ask me
to talk about hers?

I walk away
kicking the falling leaves

I carry each of you
in my heart

as the space between us

widens

 

For Mindlove’sMisery’s Sunday Writing Prompt #288.

Over the Rhine: All of my favorite people.

bravery

There is more than one list of seven virtues. Courage, or bravery, goes back to Aristotle and Plato as one of the four cardinal virtues.

What is bravery to you? An extreme sport? A warrior?

My sister endured cancer treatment for 7 years, over 30 rounds of chemotherapy. She said, “People say I am brave, but they don’t understand. I don’t have a choice. It’s do the therapy or die.” It’s still brave, though, isn’t it.

The person who comes to my mind for bravery is a woman, a long time ago. She spoke Spanish and we had a translator. Her son had had rheumatic fever and they had gone to the pediatric cardiologist for the yearly visit. Her son had a damaged heart valve that was getting worse. He was somewhere between 9 and 12.

“The heart doctor says he needs surgery. He needs the valve replaced. But the heart doctor said he could die in surgery.” she said.

I read the notes and the heart ultrasound. “The heart valve is leaking more and more. If he doesn’t have the surgery it will damage his heart. He will be able to do less and less and then he will die. If he has the surgery, there is a small chance that he will die. But if he doesn’t, he will be able to grow and to run and to be active.”

She said, “I am so afraid.” But she returned to the pediatric cardiologist. And he got through the valve replacement surgery and did fine.

That is courage to me. The parents who take chances for their children: get into boats to escape war. Search for treatments. Fight for their home, their children, their loved ones. It is both men and women, mothers and fathers, grandmothers and grandfathers, and people who have no blood relation to a child that they reach out to help. Adoption, volunteering in schools, supporting a student, supporting an organization that helps children grow and thrive.

For the A to Z challenge….and last year.

 

 

 

 

Heart call

I am lying in bed and missing my heart.

I prayed to the Beloved to fall in love and I do. I happen to be terribly sick because the Beloved is teaching me to take time off and not just work harder and longer to avoid grieving. This is the second lesson. Or the fifth, depending on how I count it. The previous one was two months, this will be ten.

But early on, before I realize that death is standing in my doorway, I am at a picnic. A sports picnic with parents and teens and some younger children. I see a man who has been flirting with me be nice to a tween girl. My heart falls out of my chest and attaches itself to him. It follows him home.

He is quite spectacularly wrong for me. I know it but my heart doesn’t care. And he is a liar, manipulator and a slut. Familiar ground, just like my family. I go to his place and try to catch my heart, but it is stubborn and skitters away from me. It is covered with sawdust, cat hair and motor oil. Also rabbit fur. He raises bunnies for meat and kills them. I cuddle the babies and then he does too.

My heart is brutally stubborn. I tell it it is stupid, it will get hurt, he doesn’t want it, all the usual stuff. I think the Beloved is laughing at me. By January I revise my prayers. Ok, Beloved, you win AGAIN, I am STUPID, now I want NOT ONLY to fall in love but to fall in love with someone who loves me back. I am so stupid I can’t believe it.

The Beloved ignores me, since my heart is already gone. Damn it.

The man tells me a dream. He dreams that his son is stuffed inside a giant teddy bear to keep him safe. He is fighting a war alone, being shot at and shooting a multitude of enemies. He tells me that his son is trained. If he needs to come out of the bear, he will be angry and he is trained to kill. Another dream is of zombies coming up from the shop and attacking the door. He and a teen or two are trying to hold them off.

There are no women in his dreams. At least the ones he tells me.

Uh, Beloved? Shit. I dream of angels, as many angels as there are stars. I meet with my minister to challenge his ideas. “The people in dreams are aspects of ourselves, ok, but not angels right? I can’t have that many angels. I was raised atheist, damn it.”

“The angels are aspects of yourself.”

And zombies…well, we’re well matched on a psychic level, right? I have enough angels to handle any number of zombies and more.

I connect with his small child self, because our small child selves are so alike. Abandoned at the same age and afraid and with desperate courage.

His pattern is obvious from the start. Mapped out like a constellation. I tell my heart, but it scurries up ladders, into boats, down the metal stands, under cars. It plays among the tools. I tell it to be careful of the saws and tools and it ignores me.

He lies and ignores emails and lies again and avoids me when he’s done something that will hurt me and like, obvious, duh. I get angry, but my angels map a new path to his small child each time. Boundary after boundary after boundary.

And now I am in contact only by text. Only by distant virtual message. He is showing up again, of course, because that’s the pattern. He has tried so hard to make me angry and make me abandon him in rage. I don’t really care. He fixes the leak on my boat that I asked him about over a year ago. He texts about installing the bilge pump. He offers to bag up the cushions and put them in his loft.

No, I reply. I have room in my house.

The only things left at his shop are a broken outboard, pipe clamps that I inherited from my father and my heart. I will go to get them.

I lie in bed, thinking of getting the motor and clamps. I think of asking for my heart too. But he has never noticed that he had it. I didn’t tell him. It was obvious. And he didn’t want it. So why would I tell him now?

And then I think, I can just call my heart. I don’t need to go in person.

I call my heart. Come home, I say. He never noticed you. You could stay, but we have done everything we can. He is still fighting the zombies, he doesn’t know he is fighting himself. He is fighting his own feelings. Come home.

My heart comes home.

It is in my chest. Filthy, sawdust, bruised, motor oil, banged up, with old tears that I mended with ribbon and dental floss and sewing thread and artificial cat gut.

Welcome home, my heart. Welcome home.

This is for the Music Prompt #63: Daniel Powter Bad Day. I took the photograph on the train from Chicago, in the evening in a storm. Prayers for those hit by the hurricane and other disasters.

Harden

harden my broken heart, please, Beloved
not against you I am openopenopen evermore
I have no enemies nor none to hate
openopenopen transparent like glass they step
on my heart glass it shatters again ow shards
pierce through me all over it takes time for each
clear piece to work its way to the surface I need a
harder heart then glass how do the bodhisattvas do it I
don’t know, oh, Beloved, yet I want to remain
openopenopen even if glass is the only heart I have
I pull the shard from my bleeding chest and back and
this is not a job for sewing or ribbon or lace my
friend gave me tape with a spine printed on it I tape
my heart with boneshards it doesn’t matter anyhow no matter
how I wail and tear my clothes it is all longing

for you, Beloved

my photo from the 2012 US Synchronized Swimming Nationals

remember, the lifts are entirely swimming: no one touches bottom

submitting to Ronavon’s beWOW

Open

O for open: open water and open heart, for the Blogging from A to Z Challenge.

I kept thinking O for ocean, but the photos that I want to use are not of the ocean but of a lake. My daughter and I were there in 2012. She was a synchronized swimmer for seven years and then joined swim team in eighth grade. We went to the lake and she practiced distance swimming. She is used to a 1950s 20 yard pool. She started at the lake by swimming to a little island we call Kidnap Island. I canoed while she swam, and my cousin’s daughter came along on the first trip. They left the lake soon after that. My daughter swam farther and farther every day, with me in a canoe to ensure that no power boat would run her over.

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We were on our way to the parking lot one day, when a power boat slowed. “Long way out, aren’t you? All alone?” said one of the men. I was in a small one person canoe that only weighs 18 pounds and is really tippy. I wouldn’t take it out in any sort of nasty weather.

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“No, I am with my daughter.” I pointed to the water.

“She’s swimming? Where did you start?” he said.

I pointed back to our cabin. Far enough that he couldn’t see it.

“Really? She swam that far?” He and his friend watched my daughter power along.

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“Yes. Swim team.”

“Is she swimming to the parking lot?” The cars were still really distant.

“Yes and probably back, too.”

“Wow. I thought it was a long way for a canoe!”  They drove on, shaking their heads.

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Open water and open heart. It takes practice to swim that far. I swim about two days a week, about a mile in the pool. My daughter shakes her head: the swim team swims three to five miles at each practice, and she swims six days a week in the season. She considers me a wuss. I consider her a calorie burning machine.

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It takes practice to keep an open heart. That is what I need in my rural family medicine clinic. An open heart allows space and expansion and time for people to open up. To say things that are bothering them or frightening them or grieving them. I am back at work now for two weeks, but by the end of the day yesterday, I was tired, tired, tired, as if I had swum across that lake. I need to rest sometimes…..