New studies show less blood pressure medication safer than more

By David L. Rosenbloom

There is an old adage that goes: "If something is good, than a whole lot more of it is better." An article in today's New York Times once again proves the adage false (Diabetes Heart Treatments May Cause Harm By Gina Kolata, March 14, 2010).

Aggressive treatment strategies by doctors attempting to help people with Type 2 diabetes don't necessarily work. In fact they can endanger them further. Studies, released yesterday at the American College of Cardiology meeting and being published online by the New England Journal of Medicine, indicate that taking additional drugs to lower blood pressure below 130 systolic actually raised the risk of stroke, heart attacks and death by 50%. Patients taking an average of 3.4 BP drugs were likely to suffer severe side effects like high potassium and dangerously lower BP when compared to those taking an average of 2 BP drugs.

This brings into question national blood pressure guidelines which recommend a systolic pressure of 130 or lower. The studies found that those with lower BP were worse off than people whose BP was in the 130-140 range.

People with diabetes also tend to have low levels of good cholesterol (HDLs) and high levels of triglycerides, giving them a higher risk of heart disease. The studies found that taking a class of drugs called fibrates, in addition to statins to improve cholesterol levels, did not help.

High BP appears to be the cause of my kidney loss in 2002. I am not diabetic. Yet in my experience in order to control my BP more effectively I needed fewer rather than more BP medications. In over a year of experimenting with many BP drugs (some of which had very adverse side effects), my former nephrologist could not control my BP levels. I finally took matters into my own hands and saw a blood pressure specialist who correctly prescribed two medications and proper doses to quickly bring my BP into the 140-145 range. Since my kidney transplant in 2008, I have been on low doses of 2 BP drugs and my BP at rest averages 135-125 systolic / 75-65 diastolic.

As I have found, drugs by themselves are only part of the answer. Good diet, regular exercise and a positive mental attitude that helps reduce stress, are major components toward better health.

Comments

[Peter Laird, MD]

Dear David, welcome aboard DSEN. Your post revives the old discussions on the J point of HTN control. Sometimes finding the optimal treatment goals is difficult. This is one such issue.

[Denise Eilers, RN, BSN]

The March 13 issue of Lancet contained an article about B/P VARIABILITY as a risk factor for stroke. "Health Day" carried a synopsis of the article. Interesting piece! I wonder what short, thrice weekely dialysis with its inherent swings in B/P would reveal about C/V events and stroke in dialysis patients.

[Bill Peckham]

There is also the question of are people having their BP correctly taken? At the ADC there was clear data showing that a low predialysis BP, systolic 100 - 110, had more risk associated with it than a high BP, 150 - 160. Even a predialysis systolic BP of 200 had less risk associated with it then a pre dialysis systolic of 100.

I think there is a dialysis effect on BPs above and beyond the "lab coat" or "white coat" effect. These days a lot of medicine is being done based on pre dialysis BP. I think that at the very least home BP monitoring should be done before meds are changed.

Home BP monitoring could be very helpful in determining if a dialyzor was appropriately hydrated. BPs taken between treatments would be very instructive to a good clinician.

[Kidneyhelp]

I couldn't agree more!  In fact I think that too many doctors and nurses take a patient's BP initially upon entering the examination room when the patient is not at rest. It invariably happens to me and I insist they come back ten minutes later and redo.  If I enter the room at 140 diastolic, ten minutes later it is down to 125. Case closed.  I always monitored my BP at home when I was in-clinic, and invariably it was lower than pre-dialysis. 

[Peter Laird, MD]

Home BP monitoring which is one of Bill's cherished goals of therapy is a very useful tool for physicians. The doctors office is not the best place to obtain reliable measurements. I tried to train my patients to do their own monitoring with reliable machines at home. My nurses would take the patients BP with our monitors and then have the patient use their machine right there in the office to see how well the two compared. For a patient that had a reliable home machine, I used their records to adjust therapy when I felt they were doing accurate monitoring. My patients appreciated the arrangement.

[Denise Eilers, RN, BSN]

I teach beginning nursing students and teaching them to take a B/P correctly is a very high priority. Factors such as cuff placement, correct cuff size, cuff applied neither too loose or too tight--all of these things matter. I also stress the importance of RESTING blood pressure and readings over time. My students report that patients have repeatedly told them that "no one else makes me rest before checking it." Solid fundamentals and back-to-basics can make all the difference!