Tis the Season to be Jolly, Unless You’re a Heart!

Like many of you, the holidays are my favorite time of the year. Unfortunately, our hearts aren’t quite as keen on the occasion. So what with all the ballyhoo over Ebola — and not to worry, we’ll be back with scary infectious diseases with my next posting — let’s talk about something that might actually kill you or one of your loved ones this year. How’s that for the Christmas spirit!

The_Santa_Clause[1]SONY DSC
Popular culture — possibly part of the problem??? But oh so much fun!

The holiday season, especially the time between Christmas Day and New Year’s Day, carries with it an increase in cardiac death. The reasons for this are still somewhat debatable, but an interesting 2004 study published in Circulation attributed the effect at least in part to the duel threat of increased stress and a delay in people seeking medical care. This makes a lot of sense as we already know that the most common time of day for suffering a heart attack is in the morning due to levels of stress hormones, specifically corticosteroids, being highest at that time of the day. This increase in stress hormones increases strain on the heart and makes it more likely that a plaque in a coronary (heart-feeding) artery will rupture and cause the heart tissue that it feeds to die — a heart attack (myocardial infarction). Furthermore, hospital workers from coast-to-coast invariably will attest to the fact that the holidays are usually a slow period around the hospital. Since it’s safe to assume that this isn’t because Christmas and New Year’s Eve don’t magically make people less sick it logically follows that sick people must be putting off going to the hospital on these important family holidays. Unfortunately, ignoring a bad situation, especially a heart attack, is the one sure way to transform it into worse news, the take home message being that if grandpa is feeling sick at the Christmas party you should really put his butt into the car and drive him to the nearest ER for evaluation whether he likes it or not.

640px-The_Waltons_1974

I ain’t need no doctor. What I need is some a’ this bacon off a’ this ole hog!

Holiday Heart is another interesting holiday phenomena. Holiday Heart is an irregular heart rate that classically affects otherwise healthy young people after a drinking binge. The exact causation is unknown, but excessive alcohol (and it generally takes A LOT) consumption somehow screws with the conduction system of the heart and can push it into a pathologic rhythm called atrial fibrillation. Recall the normal conduction system of the heart, which is nicely reviewed in this diagram (don’t be lazy, it only takes 10 seconds to get it).
2018_Conduction_System_of_Heart[1]

The normal conduction system of the heart is illustrated by the yellow arrows. The electrical current flows from the SA node (the pacemaker of the heart) down the atria to the AV node and then to the ventricles. The electrical current causes the muscle cells of the heart to contract. This system allows the atria (top of the heart) to contract first, filling the ventricles, which then contract slightly later to pump blood to the rest of the body. Venous blood from the body flows into the right atrium (located on the upper left-side of the diagram — medical diagrams are drawn as if you were facing the patient) which then pumps blood to the right ventricle ,which then pumps blood to the lungs where it is oxygenated. Blood from the lungs flows back to the heart via the pulmonary veins, which empty into the left atrium (upper right hand corner of the diagram — again, imagine that you are facing the patient). The left atrium dumps its blood into the left ventricle which then contracts to pump blood to the entire rest of the body.

Heart_conduct_atrialfib[1]

In atrial fibrillation the electrical current in the atria goes totally screwy. Instead of moving in one direction, from the top of the atria to the AV node and then on to the ventricles, the electrical current in atrial fibrillation zips around the atria every which way. So instead of a nice regular current reaching the AV node (and then the ventricles) every second or so, the heartbeat in atrial fibrillation sometimes skips beats and sometimes goes really fast. The skipping beats is usually what scares people enough to go to the ER, but it’s actually the speeding up of the heart, which sometimes last just a few seconds but sometimes can last hours, that is really dangerous and that can even cause the heart to fail.

The good news about Holiday Heart is that it usually self-resolves (goes away on its own) within about 24 hours. The bad news is that if it doesn’t resolve within less than about 24-48 hours then the treatment is anticoagulation followed by electrical cardioversion. Electrical cardioversion is shocking the heart back into a normal rhythm with electrical pads, and you have to be anticoagulated first because the irregular rhythm of atrial fibrillation (if it persists) predisposes the body to forming blood clots in the heart. Shocking a heart with a big honking blood clot hanging out in the atria back into a regular rhythm is a bad idea because it can dislodge the clot and cause a massive stroke. This is the reason why most people (generally the elderly) who have chronic atrial fibrillation have to be on lifelong anticoagulation.

Warfarin_bottles_NIGMS
The most commonly prescribed anticoagulant for patients with chronic atrial fibrillation, Coumadin is both an extremely nasty drug and a drug that has prevented untold thousands of strokes. As with any medical intervention, it’s all about risks vs. benefits. Interestingly enough, Coumadin is also used in very high doses as rat poison. Rats are very intelligent creatures and it is difficult to design a poison that they don’t recognize and start avoiding after a few rats have died from eating it. Coumadin and its related compounds avoid this by slowly poisoning rats over time. The rats eventually bleed to death, but it takes way too long for the them to be able to identify the source of the poison. Coumadin works by inhibiting vitamin K, which is used by the liver to produce the clotting factors that exist in blood and that are activated when the body suffers damage that causes bleeding. One of the most common treatments for inadvertent Coumadin overdoses in humans is vitamin K, which is generally orally administered in present clinical usage.

Finally, I would be remiss not to briefly address heart failure exacerbations, which are extremely common around the holidays. Recall that blood from the body returns to the heart after delivering its oxygen through the veins. Heart failure occurs when the heart is unable to effectively pump the blood that is returning to it back to the body. Heart failure is failure of “the pump” and this causes fluid (blood and blood plasma) to back up into the lungs (left-sided heart failure), the body (right-sided heart failure), or both (combined heart failure). Patient’s with known heart failure are treated with medications that help the heart to fill with blood better, to pump blood more efficiently, and with diuretic drugs to decrease the amount of excess fluid and salt in the body (fluid follows salt in the body via the principle of osmosis; more salt retention = more fluid retention). The holiday cheer, with all of its salty foods and free-flowing goblets often results in a heart failure exacerbation for sufferers of this disorder who carelessly imbibe excessively.

Combinpedal

Pitting edema. A classic sign of a right-sided or combined heart failure exacerbation that is caused by the accumulation of excessive fluid and salt in the peripheral tissues. The most common cause of heart failure exacerbations is failure to adhere to salt and fluid dietary restrictions (medication noncompliance is a close runner-up).

Doc’s fiction and nonfiction books are on sale for the holidays. 99 cents on Kindle and sharply discounted in paperback as well. Click on the book covers and check them out! Thanks for reading!

The Life of a Colonial FugitiveIntrusive Memory E-Covershutterstock_97052615The Cannabinoid Hypothesis

 

Dr. Leonardo Noto

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 16-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The opinions voiced on this medical blog are solely the author’s own and they do not reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.

REFERENCES

1. The Santa Clause: http://en.wikipedia.org/wiki/The_Santa_Clause#mediaviewer/File:The_Santa_Clause.jpg.

2. Milk and Cookies: English: This photo was taken by Evan-Amos as a part of Vanamo Media, which creates public domain works for educational purposes. Please visit my other galleries and projects for other free media. http://commons.wikimedia.org/wiki/File:Oreos-%26-Milk.jpg

3. The Waltons: http://en.wikipedia.org/wiki/Will_Geer

4. Philips, David et al. Cardiac Mortality Is Higher Around Christmas and New Year’s Than at Any Other Time. Circulation. 2004;110:25 3743.

5. Electrical Conduction System of the Heart: http://commons.wikimedia.org/wiki/File:2018_Conduction_System_of_Heart.jpg. Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013.

6. Atrial Fibrillation Image: http://commons.wikimedia.org/wiki/File:Heart_conduct_atrialfib.gif. Content: Skizze Erregungsleitung im Herzen bei Vorhofflimmern
author: J. Heuser –~~~~ {{GFDL-self}} Category:Physiology Category:Heart

7. Coumadin: http://commons.wikimedia.org/wiki/File:Warfarin_bottles_NIGMS.jpg

8. Pitting Edema: James Heilman, MD. http://en.wikipedia.org/wiki/Acute_decompensated_heart_failure#mediaviewer/File:Combinpedal.jpg

 

The New Controversy Over Blood Pressure and Cholesterol Guidelines – Part 2

Doc’s been running around like a chicken with his head cut off for the past month, but now I’m back and ready to give you the rundown on the new cholesterol guidelines, guidelines that are hot-off-the-press and, like their blood pressure brethren, are highly controversial. Published in Circulation: Journal of the American Heart Association, the new cholesterol guidelines are under attack for all sorts of reasons, and most of these reasons, in my opinion, are unfair and are largely coming from folks who don’t understand much of what we’ve learned in the past ten years with regards to treating hyperlipidemia (“high cholesterol”). So before we delve further, let’s take a step back and review the basics.

Cholesterol is a type of lipid (fat) that naturally occurs in the body and that is essential for making the membranes of the body’s cells and the protective sheaths of the axons of nerve cells, and for serving as the precursor to a plethora of essential hormones such as aldosterone (a salt-regulation hormone), estrogen, and testosterone. Unfortunately, cholesterol also plays an integral role in atherosclerosis, a disease that is characterized by the accumulation of fatty plaques in the walls of the blood vessels. Over time, these plaques can build up to such a degree that they narrow the blood vessels, causing a lack of blood flow to the peripheral organs. In severe instances, like in people with end-stage peripheral vascular disease, the blood flow can become so compromised that it results in the death of an organ (usually the legs in peripheral vascular disease).

Dry_gangene_4th_toe[1]

Dry Gangrene caused by peripheral artery disease. Atherosclerotic plaques have decreased the blood flow to this persons feet so much that the 4th toe is beginning to die from lack of oxygen (remember that oxygen is carried by the blood). Notice that this patient has already had a previous amputation of the 1st toe (aka: “big toe”), probably due to the same disease process.

Worse yet, these atherosclerotic plaques are often unstable and can suddenly rupture. When this occurs the body’s platelets, tiny cell fragment that form blood clots, rush to the ruptured plaque and form a clot over it, aka: a thrombus. A thrombus can suddenly and completely close off a blood vessel. If this occurs in one of the coronary arteries, the arteries that supply the myocardium (heart muscle) with blood, then a heart attack is the result. If plaque rupture, followed by thrombosis, followed by arterial occlusion, occurs in the brain then the result is a stroke.  A heart attack is the death of heart muscle due to a disruption of its blood supply whereas a stroke is the death of brain cells due to the same process – and this is why your doctor cares about your cholesterol levels.

Heart_attack-NIH[1]

A good illustration of how an atherosclerotic plaque can rupture–>thrombosis–>death of myocardium (heart muscle). This is medically called a “myocardial infarction” and is known in layman’s terms as a “heart attack.”

A few decades ago drug companies began discovering medications that lowered the levels of cholesterol in the blood. The thought at the time was that since cholesterol plays such an integral role in the formation of atherosclerotic plaques, and since people living in western/developed countries tend to have much higher levels of cholesterol in the blood than folks who live on rice and beans in the developing world, that lowering cholesterol levels would help prevent the development of atherosclerosis and its sequelae—heart attacks, peripheral vascular disease, strokes, aortic aneurysms, and more. This idea caught on rather quickly and before long everyone over the age of 40-50 was getting their cholesterol checked at least once a year by their doctor and being put on medication if their bad cholesterol (aka: LDL) was above 160mg/dL, with lower numbers like 130mg/dL, 100mg/dL, or even 70mg/dL being used as the goal for folks with known heart disease, diabetes, or who had suffered from a stroke. The problem is that while there are lots of drugs that lower cholesterol levels, only one category of these drugs has been scientifically shown to decrease the risk of death from atherosclerotic disease. These drugs are called statins.

Red_yeast_rice_wine2[1]

This is red yeast rice, a rice fermented with a specific mold that has been used medicinally and as a food substance in China for thousands of years. In the 1970’s the drug companies started investigating red yeast rice and they were able to isolate the cholesterol-lowering substance that it contains. This substance was patented under the name “Lovastatin” and the first statin drug was born. Lovastatin is a fairly low-potency statin and much more powerful derivatives have since been designed by the pharmaceutical industry. The most powerful statin drug is rosuvastatin (aka: Crestor), closely followed by atorvastatin (aka: Lipitor).

Niacin, the fibrates, bile acid binding resins, and more—all of these drugs significantly lower cholesterol, but this lowering of cholesterol has NOT been shown to lower mortality (risk of dying) from atherosclerotic disease. But the statins class of cholesterol-lowering drugs does decrease mortality from these atherosclerotic diseases, including in people who have had heart attacks and strokes in the past. How the heck does that make sense? All of these classes of medications lower cholesterol, but only the statins have a mortality benefit (decreased risk of death) from cholesterol plaque-induced diseases. Why?

450px-OahuCemetery-RevSamuelCDamon-tombstone[1]

Statins have been proven in study after study to prolong the inevitable trip to the grave for people with atherosclerotic disease or who are at high risk of atherosclerosis. None of the other cholesterol-lowering drugs have shown this benefit!

Physicians and scientists think that the reason statins are so beneficial for patients with atherosclerosis, while all of the other cholesterol lowering drugs are of dubious benefit at best (and of no benefit at worst), is because statin medications have other heart and blood vessel protective effects in addition to the lowering of cholesterol levels. The mechanism of this effect is still being investigated, but the most widely accepted theory is that statins also stabilize preexisting atherosclerotic plaques, the plaques that have been building up in the walls of every Western person’s arteries since childhood due to the unhealthy Western/American diet. These stabilized atherosclerotic plaques are less likely to rupture and it is the rupturing of these plaques, followed by thrombosis, that is responsible for the overwhelming majority of heart attacks and strokes.

Blausen_0227_Cholesterol[1]

This illustration shows the slow buildup of cholesterol and inflammatory cells in the walls of a small artery. The yellow substance is a combination of cholesterol and inflammatory cells — an atherosclerotic plaque. If you have lived in a Western/developed country for most of your life you almost certainly have at least some plaques in your arteries. We know this because even Western teenagers (who have died in car accidents, etc.) have been found to have some  plaque buildup. Most heart attacks and strokes are caused by the rupture of an unstable plaque–>thrombosis–>sudden and complete occlusion of an artery. Statins decrease the buildup of these plaques by lowering cholesterol levels in the blood but also probably stabilize preexisting plaques and make them less likely to rupture. Aspirin is heart protective because it inhibits the action of platelets, the cells responsible for thrombosis of ruptured plaques. The combination of a daily aspirin and a statin is more protective than either drug alone.

The new cholesterol guidelines are based on the recommendations of a joint panel of experts from the American College of Cardiology (ACC) and the American Heart Association (AHA) and these guidelines were published in November 2013. Before the publication of the new guidelines the cholesterol goals that your doctor was promoting were based on the findings of an older expert panel called ATP III (published in September 2002). The ATP III guidelines used an algorithm to determine how high risk a particular patient was for having atherosclerotic heart disease and then recommended a goal cholesterol level based on the calculated risk. Practicing physicians then used a variety of medications to attempt to achieve this cholesterol goal, reevaluating their progress by checking lots of cholesterol blood levels until the cholesterol blood level was in the goal range. The 2013 guidelines do away with most of this based on the best medical/scientific research currently available. And as we discussed above, the best and most current research essentially shows that statin drugs make you live longer if you have atherosclerotic disease and that none of the other cholesterol-lowering drugs have this effect.

Sprit_of_'76.2.jpeg[1]

So here’s the new ACC/AHA guidelines in simplified form — drum roll!

THE NEW ACC/AHA CHOLESTEROL GUIDELINES (simplified):

A)     You should be on a statin medication if you fall into one of these four groups:

1.       If you have atherosclerosis.

2.       If your LDL cholesterol (bad cholesterol) is >190mg/dL.

3.       If you are a diabetic who is aged 40-75.

4.       If your estimated 10-year risk of atherosclerotic heart disease is >7.5% based on this risk calculator: http://my.americanheart.org/cvriskcalculator.

B)      Instead of trending cholesterol blood levels, your doctor should use the new AHA/ACC algorithms to determine if you should be on a high-intensity statin, a moderate-intensity statin, or a low-intensity statin. In other words, instead of obsessing over a blood cholesterol goal we should instead be trying to reach a goal dose of a statin medication.

QUESTIONS/CRITICISMS REGARDING THE NEW GUIDELINES (also simplified):

QUESTION #1: My cholesterol is great on (insert medication name – niacin, fenofibrate, fish oil, etc.). Why the heck should I start taking a statin?

ANSWER: It’s nice that your cholesterol looks good on paper, but remember that your cholesterol level is only a number. Only statin drugs have been shown to decrease the risk of death from atherosclerotic disease. No one argues that you can lower cholesterol numbers with other medications, the question is whether that lowering of cholesterol is doing any good! I repeat, only statin medications have been scientifically proven to lower the risk of death from atherosclerotic disease. This is probably because statin medications have other protective effects besides just lowering cholesterol.

QUESTION #2: I see a lot of commercials on television from lawyers telling me how bad statin drugs are. Do you really think that I should be taking these medications?

ANSWER: Yes, if you fit into one of the four above listed categories, with the caveat that every patient is different and that I think even more strongly that you should follow your personal doctor’s advice (and I’m not your doctor). All medications have side-effects and statins are no exception. Statins can be hard on the liver and they can also cause myalgias (muscle pains) in susceptible people. If you have a predisposition to diabetes, they can probably can push you over into the official diabetic category faster than you would have gotten there otherwise. With that said, in people who have atherosclerosis or who are at very high risk for atherosclerosis the side-effects of not taking a statin medication are also very high and very dangerous, namely a substantially increased risk of heart attack, stroke, and death! In my experience, in the overwhelming majority  of patients with atherosclerosis or who are at high risk of atherosclerosis the risks of not being on a statin greatly outweigh the risks of taking one of these medications — I do know people who are exceptions, but they are few and far between.

CRITICISM #1: What’s the deal with this new risk calculator? I heard that it’s going to put a lot more people on statins.

REPLY: Yeah, no risk calculator is perfect, but a recent (March 2014) study in the Journal of the American Medical Association found that the new risk calculator works pretty well when used for Americans (in the same issue the calculator didn’t work so well when used for populations in Europe, but that’s not who its designed for). Yes, the new risk calculator does recommend statin therapy for lots of people who probably wouldn’t have been put on these medications under the old guidelines, but you have to remember that we’re talking about the disease (atherosclerosis) that is the #1 killer of Americans, so it’s not all that surprising that lots of people are found to be at risk by a good risk calculator!

CRITICISM #2: Isn’t this just a ploy by the drug companies to get lots of people to take their medications?

REPLY: Most statins are generic now, so in my opinion this isn’t a fair criticism.

QUESTION #3: I can’t tolerate statin drugs. Isn’t there an alternative medication?

ANSWER: This is anecdotal based on my personal experiences with patients, but the overwhelming majority of patients that I’ve treated who reported being “statin-intolerant” weren’t really. I have had a handful of (mostly) little old ladies who really couldn’t tolerate these drugs, but it is rare and in my experience most people with reported statin-intolerances are really “lawyer commercial intolerant.” Statins are a big business because the disease process that they treat is so prevalent. Most of the possible alternative medications also have a ton of potential side-effects, you just don’t hear about them on TV because statins are where the potential money is for the class action lawsuit attorneys. Remember, none of the alternative drugs have shown a mortality benefit (reduction in the risk of death) in patients with atherosclerotic disease. Only the statins are proven to do this!

QUESTION #4: What’s the deal with this “high-intensity, moderate-intensity, and low-intensity” statin therapy guideline?

ANSWER: Some statin drugs are more powerful than others. The new ACC/AHA guidelines have special algorithms that your doctor can use to determine how powerful of a statin you should be on. More powerful statins tend to be more heart and artery protective, but they also tend to have more side-effects. Examples of low-intensity statins are low-dose lovastatin and pravastatin while atorvastatin (in a high dose) and rosuvastatin are high-intensity drugs.

ONE OF DOC’s BOOKS IS FREE!

THE LIFE OF A COLONIALFUGITIVE

A dark historical thriller based in the American Revolution. Free on Smashwords for your e-reader April 2014. Click on the cover image!

REFERENCES:

1. Stone et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. November 12, 2013.

2. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285(19):2486-2497. doi:10.1001/jama.285.19.2486.

3. Muntner, et al. Validation of the Atherosclerotic Cardiovascular Disease Pooled Cohort Risk Equations. JAMA. 2014;311(14):1406-1415. doi:10.1001/jama.2014.2630.

4. Dry Gangrene: http://commons.wikimedia.org/wiki/File:Dry_gangene_4th_toe.jpg

5. Heart Attack: http://simple.wikipedia.org/wiki/File:Heart_attack-NIH.gif

6. Red Yeast Rice: http://commons.wikimedia.org/wiki/File:Red_yeast_rice_wine2.jpg

7. Tombstone: http://commons.wikimedia.org/wiki/File:OahuCemetery-RevSamuelCDamon-tombstone.JPG

8. Atherosclerotic Plaques: http://upload.wikimedia.org/wikipedia/commons/0/0e/Blausen_0227_Cholesterol.png

9. Drum Roll/Drummer Boys Image: http://en.wikipedia.org/wiki/File:Sprit_of_%2776.2.jpeg

I HAVE NO PERSONAL AFFILIATION WITH THE AHA/ACC EXPERT PANEL WHO MADE THESE RECOMMENDATIONS. I DO NOT OWN STOCK IN DRUG COMPANIES AND I DO NOT ACCEPT MONEY/BRIBES/INK PENS/ETC/ETC/ETC FROM DRUG COMPANIES. UNLIKE MANY OTHERS WHO COMMENT ON THIS SUBJECT, I HAVE ACTUALLY READ THE STUDIES/GUIDELINES THAT ARE DISCUSSED IN THIS ARTICLE. NONETHELESS, PLEASE REMEMBER THAT WWW.LEONARDONOTO.COM IS A GENERAL INFORMATION AND ENTERTAINMENT WEBSITE ONLY AND THAT YOU SHOULD NOT MAKE MEDICAL DECISIONS WITHOUT ASSISTANCE AND GUIDANCE FROM YOUR PERSONAL PHYSICIAN (WHO AIN’T ME!).

Dr. Leonardo Noto

DISCLAIMER: Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The opinions voiced on this medical blog are solely the author’s own and they do not reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.

The New Controversy Over Cholesterol and Blood Pressure Guidelines

As much as I’d love to blog about UFC or great medical movies again, let’s take a break from the fun stuff and discuss something that is really important — the new hypertension (blood pressure) and cholesterol guidelines that your doctor is probably already using whether you realize it or not. Your doctor determines your goal cholesterol and blood pressure based on the medical opinion of internationally recognized panels of experts, namely the Joint National Committee for blood pressure and the American Heart Association and the American College of Cardiology consensus statement for cholesterol. In this edition of The Health and Medical Blog with a Personality we’re going to examine the new blood pressure guidelines and next time we’ll delve into the controversy over the new cholesterol targets.

800px-Mma_ground_fighting[1]

Talking about doctors fighting over blood pressure guidelines isn’t quite as exciting as watching these guys go at it, but it’s a hell of a lot more important…

“For every 20-mmHg increase in SBP beginning at 115 mmHg, or 10-mmHg increase in DBP beginning at 75 mmHg, mortality from ischemic heart disease and stroke are doubled” [Reference #1. Note: SBP = the top number and DBP = the bottom number. More on that later]. The problem with hypertension is that you don’t feel sick, even though you really are, and by the time that you DO feel sick you have a serious problem on your hands — if you’re lucky enough to still be alive, that is. The good news is that dangerously high blood pressures are easy to detect via simple screening in your doctor’s office and that hypertension is usually pretty easy to treat. Fully 1/3 of all Americans have high blood pressure (2/3 if your older than age 60) and the cost to our society of the preventable heart attacks and strokes that these people needlessly suffer every year is greater than $100 billion dollars!

510px-Parachemableedwithedema[1]

A right-sided hemorrhagic (bleeding) cerebral vascular accident (stroke) with midline shift of the brain (not good) seen on a CT scan. Strokes come in two forms: hemorrhagic and ischemic. Hemorrhagic strokes occur when a blood vessel in the brain “pops” open, often because of uncontrolled high blood pressure. Ischemic strokes occur when a clot blocks an artery in the brain. Uncontrolled hypertension substantially increases your risk for both types of stroke.

Physicians have known for at least the past few centuries that walking around with a sky high blood pressure was really bad for you. Even before we had blood pressure cuffs, doctors realized that people with abnormally strong pulses had a habit of keeling over prematurely. The problem until the late 1950s was that we didn’t have very many effective ways to treat hypertension. Yes, there was the salt-restrictive diet, that worked (and still does work) wonders in a minority of hypertensives, and we had some really nasty drugs like phenobarbital (commonly used to anesthetize lab animals prior to execution and dissection these days), but there weren’t any good choices to treat the average High Blood Pressure Joe without causing side-effects that were arguably worse than the disease. This all changed in the ’50s with the introduction of thiazide diuretics, an effective class of medications for high blood pressure with relatively few side-effects. Over the next few decades a plethora of effective classes of antihypertensives entered the market and medicine was changed forever (now the problem is getting patients to take their damn medications…).

AoDissect_DeBakey1[1]

Another potential catastrophic sequelae (side-effect) of untreated hypertension is aortic dissection. Essentially the unravelling of the largest artery in your body (the aorta) by untreated high blood pressures. The weakened aorta then ruptures and rapidly spills the majority of the body’s blood into the chest cavity, resulting in sudden death. 

The Joint National Committee (JNC) was established in the mid-1970’s to provide physicians with guidance over how and when to use our new armamentarium of antihypertensive drugs. Every 5-10 years JNC releases a report that most doctors use as their guide regarding how and when to treat your high blood pressure. JNC is a group of experts in the treatment of high blood pressure, the best-of-the-best, who get together and mull over the results of clinical trials (really big and expensive scientific studies) and then determine what your goal blood pressure should be and what treatments your doctor should use to get it there based on these scientific studies. Until a few weeks ago the results of the 7th JNC meeting, JNC-7 (released in 2003), was the final word on the treatment of hypertension and, whether you knew it or not, was almost certainly the source of the blood pressure goals and treatment guidelines that your doctor was preaching to you every time you went in for a checkup. That changed on the 18th of December 2013 with the much anticipated release of JNC-8 in the Journal of the American Medical Association.

Blausen_0486_HighBloodPressure_01[2]

Another nice artist’s rendition from the Wiki of the cardiovascular (“heart and blood vessel”) complications (“bad stuff that happens”) due to uncontrolled hypertension.

The biggest difference between JNC-7 and JNC-8 is that the JNC-8 commission only looked at the results of Randomized Controlled Clinical Trials, the highest quality scientific studies, whereas all of the prior JNC groups (including JNC-7) also considered the results of lower quality clinical evidence, including “expert opinions (the ‘two-cents’ of certain medical big shots),” when they formulated their guidelines. Let’s look at what’s changed and then we’ll argue about it!

 

 

JNC-7

JNC-8

 

 

 

Blood Pressure Goal

<140/90

Age >60 : <150/90

Age <60 : Only treat if Diastolic Blood Pressure (the bottom number) is >90. If treated, the goal is <140/90.

 

   

Blood Pressure Goal if Diabetic or Chronic Kidney Disease

<130/80

<140/90

 

   

1st Drug Choice if Medication is Required

Hydrochlorothiazide

Black Patients : Hydrochlorothiazide or Calcium Channel Blockers

 

Nonblack Patients: ACE Inhibitors/ARBs, Calcium Channel Blockers, or   Hydrochlorothiazide.

Note: Black patients tend to response less to the ACE Inhibitor/ARBs class of blood pressure medications than other populations of people do.

 

   

Other Acceptable Drug Choices

ACE Inhibitors/ARBs, Beta Blockers, Calcium Channel Blockers

Same as Above (Beta Blockers are no Longer Recommended as 1st or 2nd   Line Treatments For Hypertension by JNC-8)

 

   

The most surprising difference in JNC-7 vs. JNC-8 is the new recommendation NOT to begin treatment for people older than age 60 unless their blood pressure is >150/90 (instead of the old guideline of >140/90). The JNC-8 panel only looked at the very best clinical trials and they found evidence that 150/90 was the point where the benefits of treating folks with medications outweighed the side-effects of those medications. With that said, JNC-8 used very high criteria to define what a “good” study is. To add fuel to the debate, virtually all of the studies out there looking at blood pressure weren’t actually designed to help answer the questions JNC-8 was asking, questions like “when should we treat high blood pressure” or “what kind of drugs should we use to treat high blood pressure.” Rather, even the best of these clinical trials were generally drug company sponsored studies that were evaluating whatever particular drug the sponsoring company was trying to sell.

800px-Cheerleaders_from_the_New_England_Patriots_(2004)[1]

Drug companies fill a vital role in modern medicine, designing the life-saving medications, vaccinations, and medical devices that have revolutionized the human experience in the past century. However, they also do a lot of ethically “questionable” things, like hiring former cheerleaders to market drugs to male doctors, bribing doctors with “continuing medical education” cruises and golf outings, using indigent people in piss-poor countries as their research subjects (and sometimes “doctoring” the results of these studies), and promoting drugs for “off-label” uses of questionable value (and etc., etc.). Studies that are funded by drug companies are important because who the heck else is going to fund this stuff (!), but remember to take them with a grain of salt.

There was a vocal minority in the JNC-8 commission (see their dissenting paper listed in the “References” section below) that argues that there is a clear decline in heart disease and stroke when  <140/90 is used as the blood pressure goal and that the side-effects of treating people to this goal, especially increased falls, don’t really become a significant problem in most patients until they are older than age 80. This minority of experts argues that <140/90 is a more appropriate goal for patients who are younger than age 80. The take home message is that this is still very much a topic of debate and that you should have a discussion with your doctor regarding your personal blood pressure goal since your physician knows you better than the experts who wrote the general guidelines (e.g. Are you at high risk for falls? Then maybe your personal blood pressure goal should be >150/90. Have you had a hemorrhagic stroke in the past but aren’t a particularly high fall risk? Then maybe your personal blood pressure goal should be lower.).

429px-Hematoma_Feb_07[1]

A large hematoma (essentially a huge bruise caused by a deep collection of blood) after a hip fracture. Untreated hypertension is a leading cause of disability and death due to preventable strokes, heart attacks, kidney failure, and aortic dissections (etc.). However, overtreated hypertension can also be dangerous due to increased risk of falls.

385px-Rt_NOF[1]

A fractured (broken) hip on X-ray. Falls are a common cause of hip fracture in the elderly, and hip fractures are a common cause of permanent disability and even death in this population. On the other hand, strokes and heart attacks are also a rather common cause of disability and death in the elderly, and untreated (or undertreated) hypertension substantially increases your risk of having both. As with most things in medicine, the treatment of hypertension is a balancing act that should be managed by an experienced physician — and sometimes there isn’t a right answer, just the least wrong one.

The other major changes were the higher (<140/90 instead of <130/80) blood pressure goal for diabetics and persons with chronic kidney disease, the consensus not to treat people younger than 60 unless their diastolic blood pressure (the bottom number) was >90, and the removal of beta blockers from the recommended 1st or 2nd line blood pressure medication treatment options. The higher blood pressure goal for diabetics and in chronic kidney disease were based on an expert consensus statement because high quality evidence is limited (i.e. there isn’t a lot of it out there) — the expert consensus of the JNC-8 panel is at odds with the expert consensus statements of several prominent diabetes and kidney organizations, so again, speak with your doctor to determine what you personal goals should be based on your unique medical situation because this is still a gray area issue.

The blood pressure goal for folks younger than age 60 also suffered from a paucity of quality evidence. In my personal opinion a blood pressure goal of <140/90 is reasonable for most folks who are younger than 60 (you’re not likely to be a high fall risk at this age), but you should be aware that the best clinical evidence only supports treating hypertension in this age group if the diastolic (bottom number) blood pressure is higher than 90. The final major change in JNC-8 was regarding beta blockers for the treatment of hypertension. Beta blockers are good drugs for protecting the heart when someone has heart disease. However, they tend to be wimpy drugs when used soley for the treatment of hypertension, which is why they aren’t recommended by JNC-8 as a 1st or 2nd line drug for folks with high blood pressure anymore. With that said, a lot of patients with high blood pressure have another medical condition like heart disease for which beta blockers are indicated, so don’t be surprised if your doctor prescribes one of these medications if this describes you.

800px-Carvedilol-I-3D-balls[1]

This is the chemical structure of carvedilol, aka: Coreg, a type of beta blocker medication. The beta blockers studied by JNC-8 (the ones that don’t work well for high blood pressure) were “cardioselective” beta blockers. Carvedilol, on the other hand, is a “broad spectrum” beta blocker that additionally blocks alpha receptors, another important drug target in the treatment of hypertension. In my clinical experience, drugs like carvedilol are substantially more effective in the treatment of hypertension than the cardioselective beta blockers that  the JNC-8 panel studied. Unfortunately, JNC-8 didn’t address this category of drugs.

In a nutshell, as with most major guidelines in medicine, JNC-8 begged two questions for every one that it answered. Remember that guidelines are an important part of medicine, but also remember that you are a unique person, with a unique constellation of health attributes and health problems, and that you should always discuss your treatment options and goals with your personal physician to make certain that you are both on the same page when it comes to your health!

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis. Amazon Link to Doc’s Writing:  http://www.amazon.com/Leonardo-Noto/e/B00ATVOMCW/ref=ntt_dp_epwbk_0

NOTE: The Life of a Colonial Fugitive — my dark historical thriller — is free for your e-reader at http://www.smashwords.com/books/view/215272. Thanks for reading!

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 20-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!

The opinions voiced on this medical blog are solely the author’s own and they do not reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.

REFERENCES:

Jackson, James H. et al. Blood Pressure Control and Pharmacotherapy Patterns in the United States Before and After the Release of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment. J Am Board Fam Med. 2008;21(6):512-521. http://www.medscape.com/viewarticle/583572

Basile, J and Ventura, H. A Historical Look at Hypertension: Celebrating 100 Years with the Southern Medical Association. Southern Medical Journal:  December 2006 – Volume 99 – Issue 12 – pp 1412-1413. http://journals.lww.com/smajournalonline/fulltext/2006/12000/a_historical_look_at_hypertension__celebrating_100.36.aspx

James, Paul A. et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). Journal of the American Medical Association. doi: 10.1001/jama.2013.284427. Published online December 18, 2013.

Wright, Jackson T. et al. Evidence Supporting a Systolic Blood Pressure Goal of Less Than 150 mm Hg in Patients Aged 60 Years or Older: The Minority View. Annals of Internal Medicine. 2014 American College of Physicians.

Brett, Allan S. JNC 8 Has Finally Arrived. NEJM Journal Watch. January 15, 2014. Vol. 34 No. 2.

CT of Hemorrhagic Stroke. http://en.wikipedia.org/wiki/Stroke
Haggstrom, Mikael (Wikipedia/Wikimedia Commons). High Blood Pressure Complications Graphic. http://en.wikipedia.org/wiki/File:Main_complications_of_persistent_high_blood_pressure.svg