Medicine
My latest Medscape commentary concerns the primary care implications of the SPRINT trial of lower systolic blood pressure goals in patients at high risk for cardiovascular disease, whose initial findings appeared last week in the New England Journal of Medicine. My bottom line for clinicians is: don't throw out the JNC 8 guideline and blood pressure targets just yet. Here's a representative excerpt from the commentary:
It's worth noting that the SPRINT results do not completely upend JNC 8. SPRINT focused on an especially high-risk population of adults with hypertension who were aged 50 years or older and had an average Framingham risk score of 20%. Patients with diabetes or a history of a stroke were not included. According to a companion study published in the Journal of the American College of Cardiology, only 1 in 6 US adults currently receiving blood pressure treatment would have been eligible to participate in this trial. Until new treatment guidelines emerge, I think it is premature to extrapolate these findings to the majority of patients at lower cardiovascular risk—and therefore less likely to benefit—but equally vulnerable to the increased adverse effects observed in this study.
Another key point: The way that blood pressures were measured in this study is probably not the way they are measured in your offices. Although best practice guidelines suggest that patients should be seated and at rest for at least 5 minutes before blood pressure is measured, you and I know all too well how rarely this occurs when patients arrive late or we are running behind schedule.
Recognizing that blood pressures obtained in the office are often inaccurate, the US Preventive Services Task Force and the Community Preventive Services Task Force recommend confirming office measurements with self-measured blood pressure monitoring before starting or adjusting medications. In order to make this practice possible, and to implement lower blood pressure goals in selected patients without overtreating them, insurers absolutely must cover patients' purchase of validated blood pressure monitors and pay family physicians for the extra time it takes to make medication adjustments outside of office visits.
- Conservative, Liberal, Or Relevant Blood Pressure? We Need Studies That Are Really Relevant...
The following is a guest post from Robert Bowman, MD One set of guidelines says to loosen up blood pressure control to prevent consequences such as falls. Almost in reaction there appears a new study that indicates a need to, perhaps, tighten up control...
- Can Treating Mild Hypertension Be Too Much Medicine?
As part of a plan to improve our practice's quality of care for patients with high blood pressure, my office's nurse announces at every morning huddle which patients on that day's schedule had a blood pressure measurement of greater than 140/90...
- Why Conflicting Guidelines Can Be Good For Patients
Many of the best-read posts on Common Sense Family Doctor have voiced my strong opinions regarding guidelines. After I left my position as a staffer for the U.S. Preventive Services Task Force in November 2010, it was three years before I was tapped for...
- Uncertain Benefits Of Medicating Mild Hypertension
In the July 1st issue of American Family Physician, Dr. Janelle Guirguis-Blake commented on a Cochrane Review that found no benefits from pharmacotherapy for mild hypertension (systolic blood pressure of 140 to 159 mm Hg and/or diastolic blood...
- Telemedicine: More Than What The Doctor Ordered
Several years ago, I cared for an elderly woman with heart failure, diabetes, and high blood pressure who had at least one major health problem at every office visit. I'd get her blood sugar levels under control only to find that her blood pressure...
Medicine
Walk, don't run to implement SPRINT findings in primary care
My latest Medscape commentary concerns the primary care implications of the SPRINT trial of lower systolic blood pressure goals in patients at high risk for cardiovascular disease, whose initial findings appeared last week in the New England Journal of Medicine. My bottom line for clinicians is: don't throw out the JNC 8 guideline and blood pressure targets just yet. Here's a representative excerpt from the commentary:
It's worth noting that the SPRINT results do not completely upend JNC 8. SPRINT focused on an especially high-risk population of adults with hypertension who were aged 50 years or older and had an average Framingham risk score of 20%. Patients with diabetes or a history of a stroke were not included. According to a companion study published in the Journal of the American College of Cardiology, only 1 in 6 US adults currently receiving blood pressure treatment would have been eligible to participate in this trial. Until new treatment guidelines emerge, I think it is premature to extrapolate these findings to the majority of patients at lower cardiovascular risk—and therefore less likely to benefit—but equally vulnerable to the increased adverse effects observed in this study.
Another key point: The way that blood pressures were measured in this study is probably not the way they are measured in your offices. Although best practice guidelines suggest that patients should be seated and at rest for at least 5 minutes before blood pressure is measured, you and I know all too well how rarely this occurs when patients arrive late or we are running behind schedule.
Recognizing that blood pressures obtained in the office are often inaccurate, the US Preventive Services Task Force and the Community Preventive Services Task Force recommend confirming office measurements with self-measured blood pressure monitoring before starting or adjusting medications. In order to make this practice possible, and to implement lower blood pressure goals in selected patients without overtreating them, insurers absolutely must cover patients' purchase of validated blood pressure monitors and pay family physicians for the extra time it takes to make medication adjustments outside of office visits.
- Conservative, Liberal, Or Relevant Blood Pressure? We Need Studies That Are Really Relevant...
The following is a guest post from Robert Bowman, MD One set of guidelines says to loosen up blood pressure control to prevent consequences such as falls. Almost in reaction there appears a new study that indicates a need to, perhaps, tighten up control...
- Can Treating Mild Hypertension Be Too Much Medicine?
As part of a plan to improve our practice's quality of care for patients with high blood pressure, my office's nurse announces at every morning huddle which patients on that day's schedule had a blood pressure measurement of greater than 140/90...
- Why Conflicting Guidelines Can Be Good For Patients
Many of the best-read posts on Common Sense Family Doctor have voiced my strong opinions regarding guidelines. After I left my position as a staffer for the U.S. Preventive Services Task Force in November 2010, it was three years before I was tapped for...
- Uncertain Benefits Of Medicating Mild Hypertension
In the July 1st issue of American Family Physician, Dr. Janelle Guirguis-Blake commented on a Cochrane Review that found no benefits from pharmacotherapy for mild hypertension (systolic blood pressure of 140 to 159 mm Hg and/or diastolic blood...
- Telemedicine: More Than What The Doctor Ordered
Several years ago, I cared for an elderly woman with heart failure, diabetes, and high blood pressure who had at least one major health problem at every office visit. I'd get her blood sugar levels under control only to find that her blood pressure...