Hypertension treatment goals. Every millimeter of blood pressure counts. 4
Leading hypertension expert discusses heart disease risks at different blood pressure levels. Clinical trials show that every millimeter of blood pressure reduction matters in heart attack and stroke risk reduction. Patients who have diabetes and hypertension, it means the same cardiovascular risk factors as in patients who already had a myocardial infarction [heart attack]. Dr. Anton Titov, MD. It’s a very interesting statistic. Dr. Ehud Grossman, MD. Correct! That’s one of the old clinical trials. It showed that the risk of heart attack and stroke in patients with diabetes is much higher than in the general population. When you have diabetes, prevention of heart attacks becomes a “secondary prevention”. This means that it’s like someone who already has had a myocardial infarction. Because the risk of myocardial infarction is so high. It is the same as the risk of someone who already had myocardial infarction. That’s why not all clinical guidelines say the same. Dr. Ehud Grossman, MD. But in some clinical guidelines diabetic patients require treatment with aspirin and cholesterol-lowering medications. It is the same as in patients who had myocardial infraction in the past. It’s also very interesting that when we talk about blood pressure, we talk about differences in blood pressure goals of 10 millimeters of mercury. Many patients say, well, plus or minus 10 units of blood pressure measurement is actually not that much. But it turns out it means a lot! It’s very important when you take the individual person. It’s not the same as if you take a million patients. Dr. Anton Titov, MD. You see what is the difference in the myocardial infarctions and brain strokes when the blood pressure is lowered by 10 millimeters of mercury. Each 20 millimeters of mercury in the systolic blood pressure and 10 millimeters of mercury in the diastolic blood pressure doubles the risk of heart attack and stroke. Sometimes you see a patient with 115 systolic blood pressure. Someone with 195 – 80 mm Hg blood pressure difference increases the risk by tenfold. This is huge. So it’s very clear that blood pressure difference of 10 millimeters of mercury counts. Dr. Ehud Grossman, MD. Now for the person himself it may be different. But you take the average, you take the epidemiology of many patients. Then you understand that each millimeter of mercury in blood pressure counts. So there is no such thing as non-meaningful difference in blood pressure. Of course, patients should try to achieve the blood pressure goals in treatment that are assigned to their category of risk. The point is that the trend is not the same. When you go down from 180 to 160, the 20 millimeters of mercury difference gives you a very significant reduction in heart attack and stroke. But when you go from 140 to 120, you get less benefit. Dr. Anton Titov, MD. So that the difference about 20 millimeters of mercury depends on where you start to where you go. Of course, that’s why we say this. OK, if you go to 140, the most of the benefit you’ve already achieved by reduction from 180 to 140 of systolic blood pressure. Now, the question is what is the additional benefit from lowering from 140 to 130? Let’s say that there is an additional benefit. But it’s low benefit. Then you say. Dr. Anton Titov, MD. How much you have to pay for it? Not in money. How much you pay in side effects of medications? Dr. Ehud Grossman, MD. Then you have to wait and see if it’s worthwhile to try and lower the blood pressure 10 millimeters more. Because you can expose the patients to side effects of medications. So this is personalized medicine. That’s the difference between doing a large clinical trial on million patients or a few hundreds thousands of patients. But when you treat a specific patient, you have to balance the benefits versus the side effects. That’s why hypertension treatment guidelines are so complicated. There is a lot of room for personalized decisions that physician might take. Dr. Ehud Grossman, MD. No question! The guidelines give you just a direction. Dr. Anton Titov, MD. But do you want to go through this direction to reach the goal? It depends on the physician. It also depends on the patient himself. You have to explain to the patient what is the situation. What may be the side effects. What is the benefit and then patient decides on treatment.
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