Category Archives: Cardiovascular

Blood Pressure: How Low is Low Enough

A new clinical trial published in the New England Journal of Medicine called the SPRINT Trial ( Systolic Blood Pressure Intervention Trial ) which compares standard treatment of hypertension to a goal of a systolic BP < 140 compared to more aggressive treatment to a goal of systolic BP <120 was published on Nov. 9, 2015.  It raises many questions and makes the most recent JAH – 8 recommendations subject to reevaluation.  In the SPRINT Trial almost 10,000 patients with hypertension felt to be at high risk to have a heart attack or stroke were randomly divided into two groups.  Standard treatment was to treat to a goal BP of <140 systolic.  Aggressive treatment was to treat to a goal of systolic BP <120. Patients with diabetes were excluded as were patients with a prior stroke.

The SPRINT Trial was stopped early because the results were felt to be definitive and showed a reduced risk of death, death from cardiovascular events like heart attack or stroke, and risk of having a non-fatal heart attack or stroke were all lower in the aggressive treatment group.  The statistical chance of an individual having a better outcome with more aggressive treatment is modest.  It would take treating 61 patients (Number needed to treat = NNN) to a goal BP of 120 vs 140 to prevent one heart attack or stroke, and the NNN for death from any cause was 90, and for cardiovascular death was 172.

The risk of serious adverse effects of medication including fainting, low blood pressure, non-fatal acute reduction in kidney function, electrolyte abnormality (low sodium or low potassium), or slow heart rate were slightly higher in the aggressive treatment group, and this group required on average about 1 additional prescription medication.

When JNC-8 (Joint National Committee on treatment of hypertension- 8th report) was released in 2014 the major change in hypertension treatment recommendations was less aggressive treatment for systolic hypertension in older patients (>60 yo) and in diabetic patients.  They recommended settling for a systolic BP of <150 in patients over 60 yo and for a systolic BP of 140 (vs the prior goal of <130) for diabetics.

Where all of this will fall out in practice remains in question, but I think pushing patients to a goal systolic BP of <120 is going to become more common, although even in this study the aggressive treatment group achieved an average systolic BP of only 121.  It is widely believed that less than half of Americans with hypertension achieve a goal of <140 currently.  Obviously it’s not going to be easy to achieve a goal of systolic BP <120 for many patients,  but at a minimum I think backing off on BP treatment for patients whose systolic BP gets into the 100-120 range and is assymptomatic is no longer reasonable, even when patients complain about how many pills they are taking and whether any of their meds can be stopped.
 

Personal Experience on a High Plant Based-Low Fat Diet

This post is unlike any I’ve put up over the years of DrPullen.com  It is largely anecdote and not based on enough hard data that I will convince my physician friends.  Intrigued?  Read on. My son Brett has been on a journey with his diet and health over the last few years.  He has become… Continue Reading

You- Yes YOU Can Save a Life by Using an AED

This week Sound Family Medicine purchased a replacement AED (automated external defibrillator) for my clinic. I underwent a training session for use with the new device. It took about 1 minute. Open the container. Apply the pads. Turn on the machine. If it says to shock the patient make sure no one is touching the… Continue Reading

Preventing Death After a Heart Attack

Cardiovascular disease remains the leading cause of mortality in the U.S.  It causes leading to of every six deaths. On hospital discharge many patients are dismayed at the number of pills they are asked to take every day.  Often they had felt perfectly healthy prior to the sudden cardiac event, and may have taken pride… Continue Reading

Reaction to JNC-8 from a Practicing Family Doc

is Practicing physicians rely heavily on certain widely accepted guidelines to set goals and make treatment decisions for our patients.  Among the most respected and followed guidelines are those of the Joint National Committee on recommendations for the diagnosis and treatment of hypertension, often simply referred to as JNC.  The JNC came out with its… Continue Reading

Have You Heard or Non-compaction Cardiomyopathy

If you have never heard of non-compaction cardiomyopathy you are in good company. Every so often I have a patient who is diagnosed with a condition I’ve never heard about, and today that was non-compaction cardiomyopathy.  Cardiomyopathy I see fairly commonly, but non-compaction was something I’d never heard about.  Maybe sometime in med school I… Continue Reading

Real Costs of Apixaban vs. Warfarin for DVT

This is just a brief post to start a conversation on the cost of treatment of acute deep vein thrombosis (DVT)  with initial low molecular weight heparin plus warfarin vs the new and per-pill expensive apixaban (Eliquis®) recently approved by the FDA for this treatment of acute DVT and pulmonary embolism. Warfarin therapy has been the… Continue Reading

What Causes Obesity: The Real Answer

We just don’t know.  Simply put that’s the answer.  I came across a recent long and detailed essay in in this week’s issue of  the British Medical Journal that reviews the history of obesity research and theory.  Anyone interested in this topic, and really many of us should be interested, should read this essay.  It outlines… Continue Reading