Blood pressure: how to measure, manage, and treat high blood pressure (AMA #48 rebroadcast)

“But here, if you overshoot this, you can cause some damage. The ARBs are right there on par with the ACE inhibitors. In fact, we did an internal white paper on this very recently. The consensus view is that basically across the board, the ARBs are probably slightly better drugs than the ACE inhibitors.”

“slightly better, than the ACE inhibitor. The ACE inhibitors have been around longer. And so, one of the things that you have is you have more of them and they're cheaper. So, a lot of times people don't necessarily have a choice in them because their insurance company is going to pay for an ACE inhibitor. They're not going to pay for an ARB.”

“And I wouldn't consider myself at all an expert in the treatment of hypertension, but we typically do not like to rely on those as first-line agents and instead rely on those as add-on agents if we've maxed out an ACE inhibitor or an ARB and we still need more reduction.”

“So, that's something you want to keep in the back of your mind. It used to be, I think, the dogma that anybody with diabetes should be on an ACE inhibitor over an ARB if you're going down that path. I would say when we looked at these data, which we did for our internal white paper, we didn't see a strong enough case for that.”

“enough case for that. I thought the data were inconsistent here. So, I think I would say this: the textbook answer is for type 2 diabetes and chronic kidney disease, ACE inhibitors might offer some benefit. But I think that both of these are probably reasonable.”

“And race might also play a role here. It would appear that in African-Americans, thiazide diuretics or calcium channel blockers might actually be more effective than ACE inhibitors or ARBs or even beta blockers when it comes to reducing cardiovascular events.”

“But here, if you overshoot this, you can cause some damage. The ARBs are right there on par with the ACE inhibitors. In fact, we did an internal white paper on this very recently. The consensus view is that basically across the board, the ARBs are probably slightly better drugs than the ACE inhibitors.”

“So, in every manner that we compare them in terms of efficacy and side effects, the ARB is as good, if not slightly better, than the ACE inhibitor. The ACE inhibitors have been around longer.”

“So, a lot of times people don't necessarily have a choice in them because their insurance company is going to pay for an ACE inhibitor. They're not going to pay for an ARB. But if ACE inhibitors are causing symptoms, such as a cough, which is probably one of the more common symptoms, you want to know that you have other agents there as well.”

“ARB and we still need more reduction. I think it's worth pointing out here, by the way, that these blood pressure-lowering medications by themselves are larger than any single lifestyle factor.”

“So, that's something you want to keep in the back of your mind. It used to be, I think, the dogma that anybody with diabetes should be on an ACE inhibitor over an ARB if you're going down that path. I would say when we looked at these data, which we did for our internal white paper, we didn't see a strong enough case for that.”

“And race might also play a role here. It would appear that in African-Americans, thiazide diuretics or calcium channel blockers might actually be more effective than ACE inhibitors or ARBs or even beta blockers when it comes to reducing cardiovascular events.”

“minutes doing nothing, not talking, not doing anything. Their back is supported, their legs aren't crossed. After five minutes, blood pressure was taken with an automated cuff. This was sized properly and used in perfect, correct way, which we'll talk about in a little while later in this podcast. They would take that reading. Five minutes later, they would repeat that.”

“want to make sure people understand the different ways to measure blood pressure. And I do both a manual cuff where you're using a blood pressure cuff and a stethoscope, and then I use a couple of different automated cuffs.”

“So that's how you measure blood pressure manually. Automated cuffs have their own algorithms. On average, they're pretty good, but the gold standard, of course, is measuring manually. But if you do measure with an automated cuff, there's lots of good ones out there. But I would just say, make sure you're doing everything correctly.”

“and those readings are always consistent the automated cuffs tend to overestimate i don't know why that is i've never found a completely compelling reason but i suspect that that varies from person to person and so yours are often the automated is higher”

“it's unambiguously higher and that's using literally two of the most expensive automated cuffs that you can buy no idea if this is accurate i would just be curious if the algorithm tends to run slightly higher solely for the fact that they would”

“like i think there's just the automated cuffs are not directly measuring systole and diastole right they tend to be measuring sort of mean arterial pressure and then using some algorithm to try to impute the others but regardless and do you encourage because”

“to know that you have other agents there as well. Thiazide diuretics and calcium channel blockers are also highly efficacious. Those are easily in the 15 millimeter of mercury and 9 to 10 millimeter of mercury impact on blood pressure, but they do tend to come with more side effects.”

“to work with them on which one to take? I think there are definitely some rules of thumb on this. So, somebody who's got heart failure or reduced ejection fraction, you would want to avoid a calcium channel blocker because obviously calcium channels play an important role in contractility of the heart.”

“And race might also play a role here. It would appear that in African-Americans, thiazide diuretics or calcium channel blockers might actually be more effective than ACE inhibitors or ARBs or even beta blockers when it comes to reducing cardiovascular events.”

“to know that you have other agents there as well. Thiazide diuretics and calcium channel blockers are also highly efficacious. Those are easily in the 15 millimeter of mercury and 9 to 10 millimeter of mercury impact on blood pressure, but they do tend to come with more side effects.”

“But in the case of renal artery stenosis, you wouldn't want to be using either of those. Diuretics, we probably want to avoid in people who already have gout or significant hyperlipidemia, type 2 diabetes, because they can actually increase somewhat insulin resistance.”

“And race might also play a role here. It would appear that in African-Americans, thiazide diuretics or calcium channel blockers might actually be more effective than ACE inhibitors or ARBs or even beta blockers when it comes to reducing cardiovascular events.”

“want to make sure people understand the different ways to measure blood pressure. And I do both a manual cuff where you're using a blood pressure cuff and a stethoscope, and then I use a couple of different automated cuffs.”

“If you choose to do this, you'll need a stethoscope, of course. This is something everybody learns in medical school and nursing school. But basically, let's just assume your blood pressure is 120 over 80. You're putting a cuff over on your arm and you have a stethoscope over the brachial artery, which is a little bit”

“to medial, you'll feel a pulse. That's your brachial artery. So, you want the stethoscope sitting there, you want the cuff about an inch above the crease in your arm. And while the stethoscope is there, you insufflate the cuff and you insufflate until you feel the loss of that pulse.”

“So thiazide diuretics, calcium channel blockers, ACE inhibitors, and ARBs. Notice I didn't mention beta blockers in there. We're really not using those for first-line agents in high blood pressure. So for primary hypertension, all first-line agents are pretty much good for about 12 to 15 millimeters reduction of systolic blood pressure”

“or even beta blockers when it comes to reducing cardiovascular events. Again, I'm not talking much about beta blockers and certainly not about alpha blockers. It's not that these other categories aren't used, but they certainly would not be considered first line today.”

“variables are changing. So we see this with our patients where if they're on blood pressure medication when they come to us, but then they lose weight and they're exercising, well, their blood pressure is going to start to come down.”

“So would I love to say that I'm going to go my whole life without having to take blood pressure medication? Sure. But the second best option would be being on blood pressure medication the second I need to be on it. That parallel seems very similar to how you talk with patients about Apo B as well, which is check it often.”

“And we talked about this at length with Rick Johnson, who's a nephrologist. And his take was that salt plays a role, but the role can be reduced by drinking water with or before a salty meal. He points out that if you're getting thirsty with a salty meal, it means you've already raised sodium.”

“And if you have, you're probably also getting the increase in blood pressure. So it's really about pairing water prior to a salty meal. So salt sensitivity is sort of a quantitative trait in which an increase in oral sodium can disproportionately increase blood pressure.”

“or even beta blockers when it comes to reducing cardiovascular events. Again, I'm not talking much about beta blockers and certainly not about alpha blockers. It's not that these other categories aren't used, but they certainly would not be considered first line today. All right. So, Peter, I think that covered the vast majority of questions we received on blood pressure and kind of a”

“So you have to be a little bit careful there. There's some evidence that increasing dietary potassium, so eating potassium-rich foods, bananas, potatoes, things like that, and not doing this through supplements, by the way, because you can sort of get into a bit of trouble there, but can lower blood pressure based on the relationship that we see between potassium and analysterone in the kidney.”

“want to make sure people understand the different ways to measure blood pressure. And I do both a manual cuff where you're using a blood pressure cuff and a stethoscope, and then I use a couple of different automated cuffs.”

“So I always notice the effect. And anybody who's ever worn a CGM will tell you that if they have a horrible night of sleep, their glucose tolerance goes out the window. And so too does your blood pressure response. So if you look at either very long or very short sleep, you're going to see in all cases an increase in hypertension.”

“So you have to be a little bit careful there. There's some evidence that increasing dietary potassium, so eating potassium-rich foods, bananas, potatoes, things like that, and not doing this through supplements, by the way, because you can sort of get into a bit of trouble there, but can lower blood pressure based on the relationship that we see between potassium and analysterone in the kidney.”

“This is such an important part of the longevity playbook, and it's not sexy, right? It's not like taking rapamycin or taking some little drug that's going to whack your senescent cells or doing anything like that. I mean, this is just bread and butter primary care medicine, but it's so needle-moving.”