A Closer Look at the New Blood Pressure Guidelines

A place to get your questions answered from McDougall staff dietitian, Jeff Novick, MS, RDN.

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A Closer Look at the New Blood Pressure Guidelines

Postby JeffN » Thu Feb 01, 2018 8:43 am

In November 2017, the the ACC/AHA came out with new guidelines for blood pressure.

You can read the full guidelines here in a downloadable PDF ...

http://www.onlinejacc.org/content/early ... 017.11.005

And a summary of the new guidelines here...

http://www.acc.org/latest-in-cardiology ... e-aha-2017

And here is a chart comparing the old guidelines (JNC 7) vs the new (2017 ACC/AHA)...

Image

First, the bad news...

From my colleague, Don Forrester, MD...

"As with previous guidelines the first recommended approach is lifestyle modifications.
This was present in the last recommendations as well but for higher "numbers".
They were ignored by most organizations and prescribers that I am aware of.
If the medical industry responds like it did to the previous guidelines I predict:
• more Americans will be labeled with a "disease"
• more Americans will be prescribed anti hypertensive drugs
• An increase in the number of strokes and heart attacks due to over-treatment due to the "J" point phenomenon
• higher costs
• more morbidity and mortality with associated disability and suffering"



Now, the good news...

Diet and lifestyle is still the official recommended first line of treatment.

Let me repeat that, Diet and lifestyle is still the official recommended first line of treatment. :)

We always knew that those with “pre hypertension” were an issue as they were in a gray zone where the benefit of medication did not outweigh the risk and may have been leading to increased deaths. Dr Goldhamer reviews this issue nicely in the intro of his study on fasting and HTN.

https://www.scribd.com/document/3272720 ... pertension

"Surprisingly, 68% of all mortality attributed to high blood pressure (BP) occurs with systolic BP between 120 and 140 mm Hg and diastolic BP below 90 mm Hg."

Apparently, they now believe the benefits of treatment outweighs the risk for this group. If the treatment is diet and lifestyle, we all win. Sadly, it probably won't be.

Coincidently, there was a presentation 2 days ago at the AHA meeting on the DASH diet. While not as healthy a diet as the diet we recommend, it clearly showed that...

a) eating healthier lowers BP even in those with a higher salt intake,

b) lowering sodium alone lowers BP

c) eating healthier and lowering sodium lowers BP the most.

Journal of the American College of Cardiology; Nov. 12, 2017, presentation, American Heart Association's annual meeting, Anaheim, Calif. http://www.acc.org/latest-in-cardiology ... t-aha-2017

Maybe this will be published but there are already several older papers on the same diet showing the same results.

(UPDATE: The study is now published)

Effects of Sodium Reduction and the DASH Diet in Relation to Baseline Blood Pressure
Journal of the American College of Cardiology
Volume 70, Issue 23, 12 December 2017, Pages 2841-2848
https://doi.org/10.1016/j.jacc.2017.10.011

Also...

The DASH Diet, Sodium Intake and Blood Pressure Trial (DASH-Sodium)
JADA August 1999 Volume 99, Issue 8, Supplement, Pages S96–S104
http://jandonline.org/article/S0002-8223(99)00423-X/pdf

viewtopic.php?f=22&t=57369&p=579589#p579589

The answer remains, follow a diet based predominately on minimally processed plant foods, low in fat, sat fat and calorie density and with low/no added SOS.

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Re: A Closer Look at the New Blood Pressure Guidelines

Postby JeffN » Thu Feb 01, 2018 8:44 am

JeffN wrote:Now, the good news...

Diet and lifestyle is still the officially recommended first line of treatment

We always knew that those with “pre hypertension” were an issue as they were in a gray zone where the benefit of medication did not outweigh the risk and may have been leading to increased deaths. Dr Goldhamer reviews this issue nicely in the intro of his studies on fasting and HTN.

https://www.scribd.com/document/3272720 ... pertension

"Surprisingly, 68% of all mortality attributed to high blood pressure (BP) occurs with systolic BP between 120 and 140 mm Hg and diastolic BP below 90 mm Hg."

Apparently, they now believe the benefits of treatment outweighs the risk for this group. If the treatment is diet and lifestyle, we all win. Sadly, it probably won't be.



This recent article still says that using medication for the primary prevention of BP less then 140 has no benefit. So, the only remaining way to effectively treat this is through lifestyle and diet.


Original Investigation
November 13, 2017
Association of Blood Pressure Lowering With Mortality and Cardiovascular Disease Across Blood Pressure Levels
A Systematic Review and Meta-analysis
Mattias Brunström, MD1; Bo Carlberg, MD, PhD1
JAMA Intern Med. Published online November 13, 2017. doi:10.1001/jamainternmed.2017.6015

https://jamanetwork.com/journals/jamain ... ct/2663255

Key Points
Question What is the association between treatment to lower blood pressure and death and cardiovascular disease at different blood pressure levels?

Findings In this systematic review and meta-analysis, including 74 trials and more than 300 000 patients, treatment to lower blood pressure was associated with a reduced risk for death and cardiovascular disease if baseline systolic blood pressure was 140 mm Hg or above. Below 140 mm Hg, the treatment effect was neutral in primary preventive trials, but with possible benefit on nonfatal cardiovascular events in trials of patients with coronary heart disease.

Meaning Systolic blood pressure of 140 mm Hg or higher should be treated to prevent death and cardiovascular disease, whereas treatment may be considered in patients with coronary heart disease and systolic blood pressure below 140 mm Hg, but not for primary prevention.

Abstract
Importance
High blood pressure (BP) is the most important risk factor for death and cardiovascular disease (CVD) worldwide. The optimal cutoff for treatment of high BP is debated.

Objective To assess the association between BP lowering treatment and death and CVD at different BP levels.

Data Sources
Previous systematic reviews were identified from PubMed, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effect. Reference lists of these reviews were searched for randomized clinical trials. Randomized clinical trials published after November 1, 2015, were also searched for in PubMed and the Cochrane Central Register for Controlled Trials during February 2017.

Study Selection
Randomized clinical trials with at least 1000 patient-years of follow-up, comparing BP-lowering drugs vs placebo or different BP goals were included.

Data Extraction and Synthesis
Data were extracted from original publications. Risk of bias was assessed using the Cochrane Collaborations assessment tool. Relative risks (RRs) were pooled in random-effects meta-analyses with Knapp-Hartung modification. Results are reported according to PRISMA guidelines.

Main Outcomes and Measures
Prespecified outcomes of interest were all-cause mortality, cardiovascular mortality, major cardiovascular events, coronary heart disease (CHD), stroke, heart failure, and end-stage renal disease.

Results
Seventy-four unique trials, representing 306 273 unique participants (39.9% women and 60.1% men; mean age, 63.6 years) and 1.2 million person-years, were included in the meta-analyses. In primary prevention, the association of BP-lowering treatment with major cardiovascular events was dependent on baseline systolic BP (SBP). In trials with baseline SBP 160 mm Hg or above, treatment was associated with reduced risk for death (RR, 0.93; 95% CI, 0.87-1.00) and a substantial reduction of major cardiovascular events (RR, 0.78; 95% CI, 0.70-0.87). If baseline SBP ranged from 140 to 159 mm Hg, the association of treatment with mortality was similar (RR, 0.87; 95% CI, 0.75-1.00), but the association with major cardiovascular events was less pronounced (RR, 0.88; 95% CI, 0.80-0.96). In trials with baseline SBP below 140 mm Hg, treatment was not associated with mortality (RR, 0.98; 95% CI, 0.90-1.06) and major cardiovascular events (RR, 0.97; 95% CI, 0.90-1.04). In trials including people with previous CHD and mean baseline SBP of 138 mm Hg, treatment was associated with reduced risk for major cardiovascular events (RR, 0.90; 95% CI, 0.84-0.97), but was not associated with survival (RR, 0.98; 95% CI, 0.89-1.07).

Conclusions and Relevance
Primary preventive BP lowering is associated with reduced risk for death and CVD if baseline SBP is 140 mm Hg or higher. At lower BP levels, treatment is not associated with any benefit in primary prevention but might offer additional protection in patients with CHD.
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Re: A Closer Look at the New Blood Pressure Guidelines

Postby JeffN » Thu Feb 01, 2018 8:45 am

Cardiovascular Guideline Skepticism vs Lifestyle Realism?
JAMA, December 14, 2017
doi:10.1001/jama.2017.19675

https://jamanetwork.com/journals/jama/f ... le/2666625

Philip Greenland, MD
Department of Preventive Medicine,
Northwestern University Feinberg School of Medicine,
Chicago, Illinois;
and Senior Editor, JAMA.

The US way of life is the problem, not the guidelines...

So, is the problem fundamentally with the guidelines or with the US lifestyle? Both the cholesterol and blood pressure guidelines prominently emphasize prevention and lifestyle habits.1,3 Some who have raised concern about the guidelines have often overlooked this emphasis and have focused on overmedicating patients. However, the data and the guidelines are clear: too many individuals in the United States and around the world are overweight or obese, eat unhealthy diets, fail to get recommended amounts of weekly exercise, or smoke. As a consequence, too many patients have high blood pressure: above the ideal level of 120/80 mm Hg. Too many have unhealthy blood glucose levels: above the ideal level of 100 mg/dL fasting. Too many have high blood cholesterol level: above the ideal of 200 mg/dL. The problem is not the result of rigorously developed guidelines, but rather is inherent in the high prevalence of unfavorable cardiovascular risk factors. Patients and clinicians need to focus attention where it belongs: on promotion of healthy lifestyles; prevention of the risk factors in the first place; and only when needed, use drugs to reduce cardiovascular risk, following evidence- based recommendations.

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Re: A Closer Look at the New Blood Pressure Guidelines

Postby JeffN » Thu Feb 01, 2018 8:45 am

Where the confusion has been is that patients (even those following this lifestyle) have received a mixed message.

They are told that they won't need medication till their BP hits a certain level (135 or 140 or even 160). Unfortunately, many have understood that to mean that until that level, they are not at any risk.

However, that is a misunderstanding as they are at risk. It is just that (from the traditional medical view) the doctor believes the risk of the medication is greater then the risk of the disease at those levels. That doesn't mean they are risk free.

The solution is to use lifestyle and diet to get your level down to 110/70 or below (or as best you can).

If you are WFPB/vegan and have a BP of 135/85, you are not risk free because of your diet. You still have work to do.

It’s also important to make sure your blood pressure is checked correctly, and doing it yourself at home may be the best way.

On self monitoring

Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial
The Lancet , Volume 391 , Issue 10124 , 949 - 959
http://www.thelancet.com/journals/lance ... 40-6736(18)30309-X/fulltext

"Self-monitoring, with or without telemonitoring, when used by general practitioners to titrate antihypertensive medication in individuals with poorly controlled blood pressure, leads to significantly lower blood pressure than titration guided by clinic readings. With most general practitioners and many patients using self-monitoring, it could become the cornerstone of hypertension management in primary care."


And, how to get an accurate BP

• Go the bathroom first.

• Don't drink a caffeinated beverage or smoke during the 60 minutes before the test.

• Sit quietly for five minutes before the test begins.

• During the measurement, sit in a chair with your feet on the floor and keep your legs uncrossed, and your back supported. Keep your arm supported so your elbow is at about heart level.

• The inflatable part of the cuff should completely cover at least 80% of your upper arm, and the cuff should be placed on bare skin, not over a shirt.

• Pull up your sleeve so that the cuff goes around your bare arm. Rest your arm on a table so that the cuff is at heart level.

• Don't talk during the measurement.

• Have your blood pressure measured twice, with a brief break in between. If the readings are different by 5 points or more, have it done a third time.

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Re: A Closer Look at the New Blood Pressure Guidelines

Postby JeffN » Fri Feb 23, 2018 7:20 am

Sometimes, a newcomer to the forum will post in a thread, not knowing the guidelines. I usually send them an PM letting them know the guidelines, that their post will be removed and to encourage them to repost their comment in a new thread. They usually do.

This happened to a post in this thread the other day but apparently they haven't wanted to repost it. So, I thought I would, as I thought it was of value.

Because they have chosen not to repost it, I will leave off their actual name and email (which they did include in the original post) and leave it anonymous.

You suggest 110/70 as the target, and I'd like to mention that Dr. Goldhamer states that 90/60, and even 80/50 are healthy/optimal readings.

I wanted to point this out to people, so they mentally file 110/70 as the HIGH END of the truly healthy range (and definitely not "low," except by comparison with a sick population). In my experience, as soon as people drop below 100/70, they misguidedly begin to concern themselves with being "too low" ... when actually they are on a trajectory toward superb.

I also wanted to point out that 120 systolic is actually considered a hypertensive CRISIS ... framing it in these terms may awaken some from the slumber of imagining that "normal" equates with "healthy," which it certainly does not in a population in which virtually 100% of people are walking around with elevated blood pressure.

Would you agree with these statements?


No.

I have asked Dr Goldhamer to cite any evidence supporting his statement that, "90/60, and even 80/50 are healthy/optimal readings."

He spent a long time looking for it through textbooks, research articles, etc.

He said, "It actually comes form the textbook on Clinical Hypertension by N Kaplan. He was providing his conclusion based on a comprehensive review of the literature on HBP."

I went an looked for it myself, found their original textbook and the original reference in the textbook. I said,"I have looked at your reference and don't see anything in it supporting your claim."

He then emailed the colleague from whom he was given the reference who replied that he remembered where he saw the actual data. He said...

"I only remember seeing this in a chart on his office wall and in a slide."

I said, "I have both the reference textbook, the reference study and all the related charts. There was no such comment, chart or slide anywhere in it supporting your claims. In fact, all the references and charts in the textbook only support my comments, that we should aim for a BP </= 110/70."

Here are the charts from the textbook

Image

Image

Image

So no, a systolic of 120 is not a hypertension crisis, and a cholesterol of 165 or LDL of 80 is not a cholesterol or heart disease crisis.

This reminded me of my discussion on this board about whether a cholesterol of 150 is the gold standard and/or makes one heart attack proof and about where these numbers come from and what they mean. If you are not familiar with this discussion, you can read it here..

viewtopic.php?f=22&t=21177

And this one on the optimum BMI-redux

viewtopic.php?f=22&t=52375

Biomarkers (ie., BP, Cholesterol, LDL, BMI etc) are only numbers and no one (or two) number(s) can guarantee any individual anything. We use them to identify risk factors and those who may be at risk.

So yes, aiming for a cholesterol of </= 150 and a LDL </= 70 and a BMI between 18.5 - 22.5 and a BP of </=110/70 are good goals but not the end all and be all. Some may have optimal health and never hit those numbers and some with those numbers may not be healthy.

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Re: A Closer Look at the New Blood Pressure Guidelines

Postby JeffN » Sun Mar 18, 2018 9:26 am

Effects of Sodium Reduction and the DASH Diet in Relation to Baseline Blood Pressure
Journal of the American College of Cardiology
Volume 70, Issue 23, 12 December 2017, Pages 2841-2848
https://doi.org/10.1016/j.jacc.2017.10.011

Abstract

Background
Both sodium reduction and the DASH (Dietary Approaches to Stop Hypertension) diet, a diet rich in fruits, vegetables, and low-fat dairy products, and reduced in saturated fat and cholesterol, lower blood pressure. The separate and combined effects of these dietary interventions by baseline blood pressure (BP) has not been reported.

Objectives
The authors compared the effects of low versus high sodium, DASH versus control, and both (low sodium-DASH vs. high sodium-control diets) on systolic blood pressure (SBP) by baseline BP.

Methods
In the DASH-Sodium (Dietary Patterns, Sodium Intake and Blood Pressure) trial, adults with pre- or stage 1 hypertension and not using antihypertensive medications, were randomized to either DASH or a control diet. On either diet, participants were fed each of 3 sodium levels (50, 100, and 150 mmol/day at 2,100 kcal) in random order over 4 weeks separated by 5-day breaks. Strata of baseline SBP were <130, 130 to 139, 140 to 149, and ≥150 mm Hg.

Results
Of 412 participants, 57% were women, and 57% were black; mean age was 48 years, and mean SBP/diastolic BP was 135/86 mm Hg. In the context of the control diet, reducing sodium (from high to low) was associated with mean SBP differences of −3.20, −8.56, −8.99, and −7.04 mm Hg across the respective baseline SBP strata listed (p for trend = 0.004). In the context of high sodium, consuming the DASH compared with the control diet was associated with mean SBP differences of −4.5, −4.3, −4.7, and −10.6 mm Hg, respectively (p for trend = 0.66). The combined effects of the low sodium-DASH diet versus the high sodium-control diet on SBP were −5.3, −7.5, −9.7, and −20.8 mm Hg, respectively (p for trend <0.001).

Conclusions
The combination of reduced sodium intake and the DASH diet lowered SBP throughout the range of pre- and stage 1 hypertension, with progressively greater reductions at higher levels of baseline SBP. SBP reductions in adults with the highest levels of SBP (≥150 mm Hg) were striking and reinforce the importance of both sodium reduction and the DASH diet in this high-risk group. Further research is needed to determine the effects of these interventions among adults with SBP ≥160 mm Hg.
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Re: A Closer Look at the New Blood Pressure Guidelines

Postby JeffN » Wed Dec 04, 2019 11:17 am

Stage 1 hypertension by the 2017 American College of Cardiology/American Heart Association hypertension guidelines and risk of cardiovascular disease events: systematic review, meta-analysis, and estimation of population etiologic fraction of prospective cohort studies.Hypertens. 2019 Nov 28. doi: 10.1097/HJH.0000000000002321.

Abstract

BACKGROUND: Epidemiological studies reported an inconsistent association between stage 1 hypertension (SBP 130-139 mmHg or DBP 80-89 mmHg) defined by the 2017 American College of Cardiology/American Heart Association hypertension guidelines and cardiovascular disease (CVD) events. In addition, the proportion of CVD events that could be prevented with effective control of stage 1 hypertension is unknown.

OBJECTIVES: To assess the association between stage 1 hypertension and CVD events and estimate the population etiologic fraction.

METHODS:PubMed, Embase, and Web of Science databases were searched from 1 January 2017 to 22 September 2019. Normal BP was considered SBP less than 120 mmHg and DBP less than 80 mmHg. Hazard ratios and 95% confidence intervals (95% CIs) were pooled by using a random-effects model.

RESULTS: We included 11 articles (16 studies including 3 212 447 participants and 65 945 events) in the analysis. Risk of CVD events was increased with stage 1 hypertension versus normal BP (hazard ratio 1.38, 95% CI 1.28-1.49). On subgroup analyses, stage 1 hypertension was associated with coronary heart disease (CHD) (hazard ratio 1.30, 95% CI 1.20-1.41), stroke (1.39, 1.27-1.52), CVD morbidity (1.42, 1.32-1.53), and CVD mortality (1.34, 1.05-1.71). The population etiologic fraction for the association of CVD events, CHD, stroke, CVD morbidity, and CVD mortality with stage 1 hypertension was 12.90, 10.48, 12.71, 14.03, and 11.69%, respectively.

CONCLUSION: Stage 1 hypertension (130-139 80-89) is associated with CVD events, CVD morbidity, CVD mortality, CHD, and stroke. Effective control of stage 1 hypertension could prevent more than 10% of CVD events.
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Re: A Closer Look at the New Blood Pressure Guidelines

Postby JeffN » Sun Jun 14, 2020 8:07 am

Lowest risk was at a Systolic Blood Pressure of 90-99. (And no, this doesn't mean a SBP over 120 is a hypertensive crisis.)

Association of Normal Systolic Blood Pressure Level With Cardiovascular Disease in the Absence of Risk Factors
JAMA Cardiol. doi:10.1001/jamacardio.2020.1731 Published online June 10, 2020.

https://jamanetwork.com/journals/jamaca ... ct/2766469

Key Points

Question:
Is there an association between normal systolic blood pressure values as currently defined and atherosclerotic cardiovascular disease among persons without traditional cardiovascular disease risk factors?

Findings:
In this cohort study including 1457 participants without atherosclerotic cardiovascular disease, beginning with a systolic blood pressure level of 90 mm Hg, there was a stepwise increase in the prevalence of traditional atherosclerotic cardiovascular disease risk factors, coronary artery calcium, and the risk of atherosclerotic cardiovascular disease. For every 10-mm Hg increase in systolic blood pressure, there was a 53% higher risk for atherosclerotic cardiovascular disease.

Meaning:
These results highlight the importance of primordial prevention to maintain optimal systolic blood pressure levels as well as optimal values of other traditional atherosclerotic cardiovascular disease, all of which generally have similar trajectories of risk within conventionally considered normal ranges.

Abstract

Importance:
The risk of atherosclerotic cardiovascular disease (ASCVD) at currently defined normal systolic blood pressure (SBP) levels in persons without ASCVD risk factors based on current definitions is not well defined.

Objective:
To examine the association of SBP levels with coronary artery calcium and ASCVD in persons without hypertension or other traditional ASCVD risk factors based on current definitions.

Design, Setting, and Participants:
A cohort of 1457 participants free of ASCVD from the Multi-Ethnic Study of Atherosclerosis who were without dyslipidemia (low-density lipoprotein cholesterol level ≥160 mg/dL or high-density lipoprotein cholesterol level <40 mg/dL), diabetes (fasting glucose level ≥126 mg/dL), treatment for hyperlipidemia or diabetes, or current tobacco use, and had an SBP level between 90 and 129 mm Hg. Participants receiving hypertension medication were excluded. Coronary artery calcium was classified as absent or present and adjusted hazard ratios (aHRs) were calculated for incident ASCVD. The study was conducted from March 27, 2018, to February 12, 2020.

Exposures:
Systolic blood pressure.

Main Outcomes and Measures:
Presence or absence of coronary artery calcium and incident ASCVD events.

Results:
Of the 1457 participants, 894 were women (61.4%); mean (SD) age was 58.1 (9.8) years and mean (SD) follow-up was 14.5 (3.9) years. There was an increase in traditional ASCVD risk factors, coronary artery calcium, and incident ASCVD events with increasing SBP levels. The aHR for ASCVD was 1.53 (95% CI, 1.17-1.99) for every 10-mm Hg increase in SBP levels. Compared with persons with SBP levels 90 to 99 mm Hg, the aHR for ASCVD risk was 3.00 (95% CI, 1.01-8.88) for SBP levels 100 to 109 mm Hg, 3.10 (95% CI, 1.03-9.28) for SBP levels 110 to 119 mm Hg, and 4.58 (95% CI, 1.47-14.27) for SBP levels 120 to 129 mm Hg.

Conclusions and Relevance:
Beginning at an SBP level as low as 90 mm Hg, there appears to be a stepwise increase in the presence of coronary artery calcium and the risk of incident ASCVD with increasing SBP levels. These results highlight the importance of primordial prevention for SBP level increase and other traditional ASCVD risk factors, which generally seem to have similar trajectories of graded increase in risk within values traditionally considered to be normal.


Editorial
What Is a Normal Blood Pressure?
Daniel W. Jones, MD
JAMA Cardiol. Published online June 10, 2020. doi:10.1001/jamacardio.2020.1742

https://jamanetwork.com/journals/jamaca ... ct/2766467

"In this issue of JAMA Cardiology, Whelton et al1 report an analysis of data from the Multi-Ethnic Study of Atherosclerosis Study that provides insight into the association between blood pressure (BP) and incident atherosclerotic cardiovascular disease (ASCVD), as well as the prevalence of coronary artery calcium. The key finding in the analysis is that, in persons free of hypertension as currently defined, free of known ASCVD, and free of other risk factors as currently defined, the risk imposed by a BP level below the currently defined hypertensive level is continuous beginning at a systolic BP level as low as 90 mm Hg."
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Re: A Closer Look at the New Blood Pressure Guidelines

Postby JeffN » Mon Jun 15, 2020 7:25 am

Interview of the principal investigator and editorial authors

https://edhub.ama-assn.org/jn-learning/ ... r/18515544

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Re: A Closer Look at the New Blood Pressure Guidelines

Postby JeffN » Tue Oct 13, 2020 7:41 am

JeffN wrote:It’s also important to make sure your blood pressure is checked correctly, and doing it yourself at home may be the best way.

On self monitoring

Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial
The Lancet , Volume 391 , Issue 10124 , 949 - 959
http://www.thelancet.com/journals/lance ... 40-6736(18)30309-X/fulltext

"Self-monitoring, with or without telemonitoring, when used by general practitioners to titrate antihypertensive medication in individuals with poorly controlled blood pressure, leads to significantly lower blood pressure than titration guided by clinic readings. With most general practitioners and many patients using self-monitoring, it could become the cornerstone of hypertension management in primary care."


And, how to get an accurate BP

• Go the bathroom first.

• Don't drink a caffeinated beverage or smoke during the 60 minutes before the test.

• Sit quietly for five minutes before the test begins.

• During the measurement, sit in a chair with your feet on the floor and keep your legs uncrossed, and your back supported. Keep your arm supported so your elbow is at about heart level.

• The inflatable part of the cuff should completely cover at least 80% of your upper arm, and the cuff should be placed on bare skin, not over a shirt.

• Pull up your sleeve so that the cuff goes around your bare arm. Rest your arm on a table so that the cuff is at heart level.

• Don't talk during the measurement.

• Have your blood pressure measured twice, with a brief break in between. If the readings are different by 5 points or more, have it done a third time.

In Health
Jeff



Why you can't go by the readings in your doctors office and why self-monitoring is so important.

Concordance Between Blood Pressure in the Systolic Blood Pressure Intervention Trial and in Routine Clinical Practice. JAMA Intern Med. Published online October 12, 2020. doi:10.1001/jamainternmed.2020.5028

https://jamanetwork.com/journals/jamain ... le/2771670

Key Points

Question
What is the concordance between routine clinic blood pressure (BP) measurements and formal trial blood pressure measurements and does discordance vary by target trial blood pressure?

Findings
In this prognostic study of 3074 participants with 3 or more outpatient and trial BP measurements linking electronic health record (EHR) data with data from the Systolic Blood Pressure Intervention Trial, the mean systolic blood pressure recorded in outpatient electronic health records was higher than that measured in the trial. The difference between blood pressure recorded in electronic health records and trial blood pressure varied widely by site.

Meaning
These results highlight the importance of proper BP measurement technique and the potential shortcomings of comparing trial-measured BP with BP measurements from clinical EHRs.

Abstract

Importance
There are concerns with translating results from the Systolic Blood Pressure Intervention Trial (SPRINT) into clinical practice because the standardized protocol used to measure blood pressure (BP) may not be consistently applied in routine clinical practice.

Objectives
To evaluate the concordance between BPs obtained in routine clinical practice and those obtained using the SPRINT protocol and whether concordance varied by target trial BP.

Design, Setting, and Participants
This observational prognostic study linking outpatient vital sign information from electronic health records (EHRs) with data from 49 of the 102 SPRINT sites was conducted from November 8, 2010, to August 20, 2015, among 3074 adults 50 years or older with hypertension without diabetes or a history of stroke. Statistical analysis was performed from May 21, 2019, to March 20, 2020.

Main Outcomes and Measures
Blood pressures measured in routine clinical practice and SPRINT.

Results
Participant-level EHR data was obtained for 3074 participants (2482 men [80.7%]; mean [SD] age, 68.5 [9.1] years) with 3 or more outpatient and trial BP measurements. In the period from the 6-month study visit to the end of the study intervention, the mean systolic BP (SBP) in the intensive treatment group from outpatient BP recorded in the EHR was 7.3 mm Hg higher (95% CI, 7.0-7.6 mm Hg) than BP measured at trial visits; the mean difference between BP recorded in the outpatient EHR and trial SBP was smaller for participants in the standard treatment group (4.6 mm Hg [95% CI, 4.4-4.9 mm Hg]). Bland-Altman analyses demonstrated low agreement between outpatient BP recorded in the EHR and trial BP, with wide agreement intervals ranging from approximately −30 mm Hg to 45 mm Hg in both treatment groups. In addition, the difference between BP recorded in the EHR and trial BP varied widely by site.

Conclusions and Relevance
Outpatient BPs measured in routine clinical practice were generally higher than BP measurements taken in SPRINT, with greater mean SBP differences apparent in the intensive treatment group. There was a consistent high degree of heterogeneity between the BPs recorded in the EHR and trial BPs, with significant variability over time, between and within the participants, and across clinic sites. These results highlight the importance of proper BP measurement technique and an inability to apply 1 common correction factor (ie, approximately 10 mm Hg) to approximate research-quality BP estimates when BP is not measured appropriately in routine clinical practice.


Invited Commentary: A Tale of 2 Blood Pressures. JAMA Intern Med. Published online October 12, 2020. doi:10.1001/jamainternmed.2020.5007

https://jamanetwork.com/journals/jamain ... ct/2771665

In this issue of JAMA Internal Medicine, Drawz et al1 report data from the Systolic Blood Pressure Intervention Trial (SPRINT) comparing office blood pressure (BP) measured in the trial with office BP obtained during routine clinical practice. SPRINT, which enrolled adults 50 years or older without diabetes or stroke to determine whether a more intensive BP treatment target was beneficial, was stopped early after an interim analysis showed that an office systolic BP (SBP) target of less than 120 mm Hg reduced cardiovascular events and all-cause mortality compared with a standard SBP target of less than 140 mm Hg.2 As in many hypertension trials, office BP was measured using a standardized protocol that included use of an oscillometric device and appropriately sized cuff along with a 5-minute period of rest before BP was measured, proper positioning of the participant, and measurement of and calculating the mean of 3 BP readings.


Here are some of the top rated BP monitors (I make NO money from these links directly or as an affiliate)

- Omron Platinum BP5450
- Omron Silver BP5250 (Amazon)
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Jeff
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JeffN
 
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Re: A Closer Look at the New Blood Pressure Guidelines

Postby JeffN » Wed Feb 16, 2022 9:09 am

make sure you have a validated meter

The problem...

Non-Validated BP Monitors Are a Global Problem
— Thousands of device models don't meet international standards

https://www.medpagetoday.com/primarycar ... care/97197

"Automatic blood pressure (BP) monitors that are clinically validated for accuracy turned out to be few and far between in terms of worldwide distribution, despite guideline recommendations that patients use validated models, researchers found.

Devices lacking any evidence of validation made up 76.3% of the 3,411 home BP monitors listed in the commercial Medaval database, with the remainder consisting of the 8.8% known to be validated and the 11.1% deemed equivalent to a previously validated device, said James Sharman, PhD, of the University of Tasmania in Australia, and colleagues."



The Solution

US Blood Pressure Validated Device Listing
https://www.validatebp.org

"Uncontrolled high blood pressure (“BP”) is the leading risk factor for death and disability. The accurate measurement of BP is essential for the diagnosis and management of hypertension. One important aspect of accurate measurement is whether the BP measurement device has been validated for clinical accuracy."

"To address this challenge, the American Medical Association (AMA) enlisted the National Opinion Research Center at the University of Chicago (NORC) to assist in the design and management of an independent process to determine which BP devices available in the U.S. meet the AMA’s established criteria to validate clinical accuracy (the “Validated Device Listing (VDL) Criteria”). An Independent Review Committee comprised of physician experts in the BP field assesses whether a BP device satisfies the VDL Criteria for validation of clinical accuracy. This independent review process results in a formal list of BP devices that have been validated for clinical accuracy (the “US Blood Pressure Validated Device Listing” or “VDL”)."
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