New high blood pressure guidelines: Think your blood pressure is fine? Think again…11-26

The American College of Cardiology and the American Heart Association certainly grabbed the attention of us busy primary care physicians with the recent release of their updated blood pressure guidelines. These organizations had piqued interest by declaring the release date and labeling it as “highly anticipated.” I pooh-poohed all that drama, but upon reading through the 114-page executive summary PDF with 21 authors and almost a thousand references, I have to say, I am duly impressed.

The definition of the diagnosis of high blood pressure and the decision-making process surrounding treatment have traditionally been quite individualized (read: all over the place). Personally, I invite these stricter measures, because they are accompanied by solid research, logistical guidance, and useful management strategies.

However, a whole heck of a lot of people just got pulled into a significant medical diagnosis.
Let’s review what’s new.

A new definition of high blood pressure (hypertension)

(Please note that all numbers refer to mm Hg, or, millimeters of mercury.) The guidelines, in a nutshell, state that normal blood pressure is under 120/80, whereas up until Monday, normal was under 140/90.

Now, elevated blood pressure (without a diagnosis of hypertension) is systolic blood pressure (the top number) between 120 and 129. That used to be a vague category called “prehypertension.”
Stage 1 high blood pressure (a diagnosis of hypertension) is now between 130 and 139 systolic or between 80 and 89 diastolic (the bottom number).

Stage 2 high blood pressure is now over 140 systolic or 90 diastolic.

The measurements must have been obtained from at least two careful readings on at least two different occasions. What does careful mean? The guidelines provide a six-step tutorial on how, exactly, to correctly measure a blood pressure, which, admittedly, is sorely needed. My patients often have their first blood pressure taken immediately after they have rushed in through downtown traffic, as they’re sipping a large caffeinated beverage. While we always knew this could result in a falsely elevated measurement, it is now officially poor clinical technique resulting in an invalid reading.

New recommendations on monitoring blood pressure

The new guidelines also encourage additional monitoring, using a wearable digital monitor that continually takes blood pressure readings as you go about your life, or checked with your own cuff at home. This additional monitoring can help to tease out masked hypertension (when the blood pressure is normal in our office, but high the rest of the time) or white coat hypertension (when the blood pressure is high in our office, but normal the rest of the time).

There are clear, helpful directions for setting patients up with a home blood pressure monitor, including a recommendation to give people specific instructions on when not to check blood pressure (within 30 minutes of smoking, drinking coffee, or exercising) and how to take a measurement correctly (seated comfortably, using the correct size cuff). The home blood pressure cuff should first be validated (checked in the office, for accuracy).

If you now have high blood pressure, you may not need meds… yet

The guidelines also outline very clearly when a diet-and-lifestyle approach is the recommended, first-line treatment, and when medications are simply just what you have to do. Thankfully, the decision is largely based on facts and statistics. For the elevated blood pressure category, medications are actually not recommended; rather, a long list of evidence-based, non-drug interventions are. What are these interventions? Things that really work: a diet high in fruits and vegetables (such as the DASH diet, which is naturally high in potassium); decreased salt and bad fats; more activity; weight loss if one is overweight or obese; and no more than two alcoholic drinks per day for men, and one for women. Simply changing what you eat can bring down systolic blood pressure by as much as 11 points, and each additional healthy habit you adopt can bring it down another four to five points.
For people with stage 1 hypertension who don’t have cardiovascular disease and are at low risk for developing it (less than 10% risk of an event within 10 years), lifestyle changes are still the way to go.

However, if a patient has any kind of cardiovascular disease and stage 1 hypertension (a blood pressure over 130 systolic or 80 diastolic), or no existing cardiovascular disease but a significant risk of developing it (over 10% risk within the next 10 years), then lifestyle changes plus medications are recommended. And, even if someone has less than a 10% risk, if their blood pressure is over 140 systolic or 90 diastolic, which is now stage 2 high blood pressure, they ought to be treated with medication as well.

Optimizing treatment of high blood pressure

The authors bring several evidence-based yet progressive concepts into the guidelines, the first of which is that high blood pressure should be treated using a team approach. This makes sense, as science supports more and better patient education around self-monitoring, nutrition, and lifestyle changes, as well as stress management. Tele-health is emphasized as a cost-effective method of ongoing monitoring that is more convenient for patients than frequent office visits.

And why should this all matter to you?

Mountains of research over time have shown a very clear link between high blood pressure and cardiovascular disease. A 20-point higher systolic blood pressure or a 10-point higher diastolic blood pressure is associated with double your risk of death from a heart attack, stroke, or other cardiovascular complication (like abdominal aortic aneurysm or heart failure). What many people don’t realize is that those who survive these events find their lives permanently altered by disability and medical complications.

Much is being made of the fact that the new definitions of high blood pressure will mean roughly half of all US citizens will be considered to have high blood pressure, but when you really look at the numbers, as cardiologists already have, not that many more people will actually be advised to take medications. Although the public has good reason to be suspicious of “big pharma,” that’s not what this is about.

Diet and lifestyle changes are powerful medicine. Even if your blood pressure is normal now, you can help to prevent it from becoming elevated starting today. Eat more fruits, veggies, and whole grains, and limit foods high in sodium and unhealthy fats. Be as physically active as possible.
There is a lot more in the very long, detailed executive summary, including specific guidance for various populations, myriad diseases, and special circumstances, but this is the gist of it.

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Can You Reverse Heart Disease? 11-08

Can You Reverse Heart Disease?

What may be possible if you have coronary artery disease.

Imagine that you’ve just left your cardiologist’s office. He’s told you that you have to make some changes. Your blood pressure is way over the limit at 170 over 100 and your LDL cholesterol (that’s the “bad” kind) is hovering right around 200. He conducted an exercise cardiac stress test, putting you on the treadmill and increasing the speed and elevation periodically while monitoring your heart -- and he didn’t like the results.

The diagnosis: coronary artery disease (CAD).

Besides surgery or medication, is there anything you can do to modify the course of CAD? The answer to that is, clearly, yes -- as long as your doctor is on board. Making some simple but significant changes in what you eat, how often you exercise, how much you weigh, and how you manage stress can help to put the brakes on heart disease.

But can you actually reverse heart disease, not just slow it down? The answer to that question is much more controversial. Here are two expert's views.

Yes, You Can!

Dean Ornish, MD, founder and president of the Preventive Medicine Research Institute and clinical professor of medicine at the University of California, San Francisco, says that you absolutely can reverse at least some of the damage of even severe heart disease. Indeed, one of his six best-selling books is titledDr. Dean Ornish's Program for Reversing Heart Disease.

In his 2007 book The Spectrum, Ornish describes patients waiting to undergo a heart transplant -- those with the worst possible damage -- who enrolled in his program while on the transplant list. Some of them, he says, improved so much that they no longer needed a transplant.

“Our studies show that, with significant lifestyle changes, blood flow to the heart and its ability to pump normally improve in less than a month, and the frequency of chest pains fell by 90% in that time,” Ornish says. “Within a year on our program, even severely blocked arteries in the heart became less blocked, and there was even more reversal after five years. That’s compared with the natural history in other patients in our study, in which the heart just got worse and worse.”

Those lifestyle measures include exercise -- Ornish calls for people to walk at least half an hour a day, or an hour three times a week. Your cupboards, refrigerator, and dinner table will also need a total transformation if you expect to have a chance of actually reversing heart disease, not just preventing it or stopping its progression.

“Just making moderate changes in your diet may be enough to prevent heart disease, but it won’t be enough to reverse it,” Ornish says.

Ornish's plan categorizes foods from 1-5, ranging from most to least healthful. To actually reverse heart disease, you have to stay in Category 1.

In essence, that means becoming a vegetarian, filling your plate with fruits and vegetables, whole grains, legumes, soy products, nonfat dairy, and egg whites, and keeping away from fats, refined sugar, and carbohydrates. “You want to eat foods in their natural form as much as possible," Ornish says.

Ornish’s program also calls for regular yoga, meditation, and stress reduction.

If you have serious heart disease and are extremely motivated, you may be able to make such major changes, but they are difficult to sustain, says Lori Mosca, MD, MPH, PhD, professor of medicine and director of preventive cardiology at Columbia University Medical Center and the author of Heart to Heart: a Personal Plan for Creating a Heart Healthy Family.

“You have to live a very strict lifestyle, way beyond even the normal heart-healthy life,” she says. “And even then, I wouldn’t say you can ‘reverse’ heart disease, because that implies you had something and now you don’t. With very strict changes you can regress heart lesions, but they shrink -- they don’t go away. You can’t cure heart disease, but you can slow its progression.”

Mosca instead emphasizes slowing heart disease, and preventing it in the first place, through lifelong efforts to eat heart healthy, get regular physical activity, avoid smoking, and maintain a healthy weight.

On the diet side, that means embracing variety. “I don’t think that dietary approaches that are highly restrictive are sustainable,” she says. To keep heart disease in check, she advises:

Embrace the USDA’s new “MyPlate” program (similar to a visual she’s had on her Web site for years), in which half your plate is loaded with fruits and vegetables, and the other half is evenly divided between lean proteins and high-quality carbs such as brown rice.

• Limit the saturated fat in your diet to less than 7% of calories.
• Choose heart-healthy sources of fat, such as salmon and other fish rich in omega-3 fatty acids, nuts, and olives.

Ornish agrees that for most people who are just looking to either prevent heart disease or slow it down, going entirely “Category 1” isn’t needed. “If you need to reverse a life-threatening illness, you’re well advised to live as much as you can on the healthiest end of the spectrum,” he says. “But if you’re just trying to stay healthy, it’s unsustainable to say, ‘Never eat certain foods.’ It’s much more sustainable to just move in a healthier direction.”

And if you slip up and eat something that’s really not heart-healthy (a bacon cheeseburger, say, or a gooey doughnut) -- don’t beat yourself up. “If you indulge one day, then eat healthy the next. If you don’t exercise one day, do more the next,” says Ornish. “Guilt, shame, and anger are toxic to the heart, so forgive yourself and move on.”

Once you start making those changes, you might find that the rewards spur you to make more.

“We found that the more people changed their diet and lifestyle, the more they felt better, no matter how old or sick they felt,” Ornish says. “The better you feel, the more you want to keep doing it. The myth is that a pill is easy and diet and lifestyle changes are hard, but the data show that less than half the people prescribed Lipitor still take it after a year. Taking a pill to prevent something bad happening is fear-based, and it can be boring. But making healthy changes to your life makes you feel good, so you’re not just living longer, but better.”

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