 |
Leading an Assembly discussion of hypertension and evidence-based medicine, Robert Raspa, M.D., of Orange Park, Fla., had a habit of talking about the "old days" and the "new days."
There used to be four categories of hypertension, and now there are two, "not too bad" and "bad," Raspa quipped during the two-hour seminar "Hypertension and Evidence-based Treatment."
The "new days" refers to findings in the wake of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, or JNC-7.
So what is hypertension? The simple answer is a blood pressure of 140/90 mm Hg and above. But part of the new approach is to aggressively treat the condition and designate patients whose blood pressure is higher than 120/80 mm Hg as "prehypertensive," said Raspa. At the prehypertensive stage, the physician should counsel the patient about lifestyle modifications, because these patients have greater than twice the risk of developing hypertension than patients with normal blood pressure.
Raspa prefaced the lecture by talking about one of his own patients, a woman whose high blood pressure was unresponsive to changes despite repeated visits to address it. He counseled her about lifestyle changes. Still high. She took a diuretic. Still high. She took an angiotensin-converting enzyme inhibitor. Still high. Beta blocker. Still high. Again, he asked about her diet. Raspa commented, "She said, ‘I swear I'm not eating too much salt.'" Try as he might to help her lower it, her blood pressure remained stubbornly elevated.
"We slipped into an antagonistic relationship," Raspa said. But with the potential to extend a person's life by up to two years by controlling blood pressure, patients and physicians both are becoming more motivated.
"Why be more aggressive?" he asked rhetorically. "If you can keep people in the normal range when they're very young, that's where you get the most benefit, the most prevention."
The vast majority of patients with hypertension remain inadequately treated, he said.
"The good news is pharmacologic treatment works," said Raspa.
Diuretics are unsurpassed and remain the first line of treatment, he said. He challenged attendees to go back and look at their patient records to ensure that diuretics were their first line of treatment when indicated. In fact, he called his mother's physician when he learned she wasn't on a diuretic for hypertension, he told attendees.
However, pharmacologic therapy is complex, and there are always exceptions, he noted. One study showed that white males do better with an ACE inhibitor first, for instance.
He went into further detail, discussing use of particular agents with specific conditions. Finally, a small number of patients have secondary causes of hypertension and should be treated accordingly, he said.
After the lecture, physicians were able to discuss their own patients, asking advice on prevention, prescribing, complicating factors and education.
FP Report is
published by the AAFP News Department.
Copyright © 2004 by American Academy of Family Physicians.