Lowering Your Blood Pressure With Medication

Matthew DeVane, MD: [00:00:08] Hi, I'm Dr. Matt Devane.

Carolyn Lacey, MD: [00:00:09] And I'm Dr. Carolyn Lacey. We are cardiologists at John Muir Health, and this is our podcast, Living Heart Smart.

Matthew DeVane, MD: [00:00:16] Our physician partners and colleagues are going to help guide you through many different and important cardiovascular topics to help keep your heart happy and healthy.

Carolyn Lacey, MD: [00:00:24] Thank you for listening and we hope you enjoy our show.

Carolyn Lacey, MD: [00:00:32] I know nobody wants to take a medication, but sometimes we need medications for blood pressure so we can prevent the bad things like stroke, heart attack, and even death. Today, we welcome Dr. Christopher Chen to delve into the science with a couple landmark trials, talk about different medication classes and the importance of working closely with your physician to bring your blood pressure under control. Here's our episode.

Matthew DeVane, MD: [00:00:56] Today. We want to get into a little bit more about what it's like when we have to move toward prescription medications to treat blood pressure. And I think that's very important because a lot of you are going to end up on meds. So, Dr. Chen, welcome back to the show.

Christopher Chen, MD: [00:01:09] Thank you so much for having me back.

Matthew DeVane, MD: [00:01:12] Today let's start out because people wonder, you know, why I feel fine, my blood pressure's up a little bit, you know, and why do we need to use medications? And in my mind, I started thinking about a few of the clinical trials that have come to attention over the last couple of years that have really changed my mind about how aggressive we need to be at treating people's blood pressure. And the reason we need to treat blood pressure and be aggressive is because it makes a big difference in outcomes. And for me, it's all about outcomes that affects the way I treat people right. Less heart attacks, less strokes, less bad events. That's important to me, and I think that should be important to patients too. So normally I don't like to get into too much of the science and clinical trial stuff in these types of discussions. But if it's okay with you, Dr. Chen, maybe we can talk about a few of the clinical trials related to high blood pressure that help guide us toward treatment.

Christopher Chen, MD: [00:02:03] Absolutely. So one of the most recent, I think,

Christopher Chen, MD: [00:02:07] Game-changing trials was the Sprint trial. And the Sprint trial used a much more aggressive blood pressure target of 120 compared to 140 where we're treating things before. Now, it's to be said, the Sprint patients were people at higher risk of having heart disease, right? So they had some risk factors that drove us to want to be more aggressive with their blood pressure. And what they found was that patients who were treated to less than 120, compared to less than 140, had a significant reduction in terms of cardiovascular events. That's fewer strokes, fewer MIs. or fewer myocardial infarctions, and English, that's heart attacks and less cardiovascular death. And we found that to be such an important finding that the trial was actually stopped early because we felt that that was a significant clinical benefit that didn't need to wait until the full trial period resolved.

Matthew DeVane, MD: [00:03:03] I think they even called this a landmark trial because whenever they stop a trial before they're supposed to, they're seeing such dramatic decreases or changes in their outcomes with the treatment that they just shut it down and say, no, we can't do this anymore. Too many patients are at risk. Let's just get the word out and start implementing this. So that's that was crazy. Absolutely. I'm sorry. The other thing that I really liked about this trial is because it really helped me think about treating patients with high blood pressure as individuals, because, as you mentioned, the patients that were in this trial kind of had other risk factors for cardiovascular events. And it's those patients in particular that we need to be, I would say, more aggressive about getting their blood pressure into the normal range, which is lower than we used to think.

Christopher Chen, MD: [00:03:49] Yes, absolutely. So those patients the trial design was interesting because for each visit, if your blood pressure was above their specified target, they absolutely wanted the clinician to make a change to their medication regimen versus waiting until the next visit to make that change. Right. And they saw pretty fast benefits from that, that difference. So I think the importance of these patients who are at higher risk is that, hey, if the blood pressure is uncontrolled, we should definitely get on that sooner rather than later.

Carolyn Lacey, MD: [00:04:23] I think we also have this sort of feeling that having high blood pressure leads to problems down the road. And when we think about down the road, it's very, we think very far down the road. We think years down the road. And then this is a trial, though, that they saw improvement, statistical improvement, and doctors talk about statistical improvement all the time. That's that's how we live and live and work is statistical significance. They saw that they saw changes within a year.

Christopher Chen, MD: [00:04:58] Right. And so I think that's why it's important to act on this quickly. And the way I coach is this. So say that we're working on your modifiable risk factors and you're working on that every day. But because you're in a higher risk category, we have to get the medications on board too, so that we can lower things quickly.

Matthew DeVane, MD: [00:05:20] And it's not either or, right? It's both.

Christopher Chen, MD: [00:05:22] It's both. And then as things get better, we might be able to pull away some of those pharmacologic therapies, these medications. They're not forever medications, but it is important to get these things under control.

Carolyn Lacey, MD: [00:05:33] I talk about it in terms of pouncing. We have to pounce like the cats, like the kittens pouncing on you. When you walk in the door, you got to pounce on the blood pressure with medicines in order to be able to give you time to do some of these modifiable risk factors and then scale back as we are able to.

Matthew DeVane, MD: [00:05:51] The excellent. I'm ready to pounce. Nice. Now, Dr. Chen, I think you wanted to mention maybe another clinical. The trial that's kind of affected the way you think about blood pressure. Yeah.

Christopher Chen, MD: [00:05:59] So I'll wrap up the Sprint trial quickly, because one of the things we found was that, you know, when you're treating blood pressure more aggressively, you're going to be on a little bit more medication. And so the average amount of medications people are on in the Sprint trial, in the aggressive treatment arm was about 3.4. Right now, no one's actually on 3.4 medications. It's either 3 or 4 medications to get your blood pressure controlled compared to the normal blood pressure category. People were still on 2 or 3 medications. So if you're only on 2 medications and you're looking at that third, that is actually what we expect. So we expect you to be on probably on average, 3 medications. The other trial that we keep in mind when we think about blood pressure is the cord BP trial. That's a little bit older than the Sprint trial. And it looked at diabetics and it looked at intensive control, less than 120 versus 140. And so for those patients, there wasn't a whole lot of benefit from intensifying their blood pressure medicine. Blood pressure control to less than 120 then 140 There was a very minute improvement in stroke, but otherwise, there were more events of symptoms of low blood pressure feeling dizzy when you stand up, having passing out events. And so for people with diabetes, we tend to be still aggressive, but maybe not quite till the less than 120 level.

Matthew DeVane, MD: [00:07:28] I think what is important with what you said is always and you've mentioned this on another episode that we did, was always finding that sweet spot because all of the medicines that we are going to be prescribing have potential side effects. We understand that we're pretty good at finding ones that work together pretty nicely. And so that's one of our goals, is to make sure that, you know, now that we're up to two or 3 or 4 medicines that treat blood pressure, we're always going to be finding ways to make sure those work nicely together. So but we always are weighing that against the risks. So part of us evaluating your heart when you have high blood pressure and your risk will include some basic testing. So when you come to a cardiologist and have high blood pressure. Dr. Chen, can you talk about some of the things that you may expect to get as far as testing goes when you come see a doc.

Christopher Chen, MD: [00:08:15] Yeah. So the screening things that we do for anyone with hypertension is a set of blood work, and that includes looking at your kidney numbers, specifically your creatinine. And what we're looking for is evidence of chronic kidney disease. Second thing that we'll usually always get is an EKG. We want to know, do you have signs of hypertensive heart disease that we need to be worried about? And depending on those results, we may also get an echo, which is an echocardiogram or an ultrasound of your heart to further define the structure and the function of your heart. So if there's any issues with both the wall thickness, chamber sizes, valve dysfunction that affect what we are going to do for treatment.

Carolyn Lacey, MD: [00:08:54] Maybe some evidence that your blood pressure is high is giving you more problems than you recognize already that it has?

Matthew DeVane, MD: [00:09:02] Well, I think these tests are important because as we've talked about, this is the silent killer and patients may not feel anything yet. Their organs, their kidneys, their heart are already having effects. And so some of these basic tests we're doing when you start is to see if that's happening, because that will change the level of aggressiveness that we're going to go about treating your blood pressure. And secondarily, it provides us a baseline. So as we're treating you over time, we'll be able to compare how things look over time. Good. So I think we're to that point where now, despite all our best efforts and despite the patient's best efforts, we've decided that your blood pressures are too high or that your overall risks are too high, that we can't let the blood pressure stay where they are. So we're going to reach into our basket of medications. Fortunately, there are a lot of effective and safe medicines that we have available to us to lower blood pressure. So let's talk big picture here. When you think about medications, how do we start the process and how do we pick and choose?

Christopher Chen, MD: [00:10:01] Yeah. So our medications that we use for blood pressure, we think about in terms of classes. And so there are three main classes of medications that we start with. One of those are calcium channel blockers. The second one are ACE or ARBs, and the third are diuretics. And so those are the three primary first-line medications. There are many others and a frequent fourth category is beta blockers. We classify them this way because that's how they work. And so when we think about what do we need from a blood pressure standpoint, we start with the class, what mechanism, and what action we're looking for to get our desired result.

Matthew DeVane, MD: [00:10:42] And I think a lot of times also we have to take the patient's all their conditions into account when we're choosing these medications, because many times other medical conditions will help us choose the medication for blood. Pressure. Can you tell us about some of the other conditions that may affect the blood pressure medicine we're picking?

Christopher Chen, MD: [00:11:00] Yeah, absolutely. So I like to think about how many birds can we kill with one stone?

Carolyn Lacey, MD: [00:11:08] Nice, that's good.

Christopher Chen, MD: [00:11:09] So if we're dealing with someone who may have an arrhythmia issue, which is a rhythm abnormality of the heart, often beta blockers help with those patients. And so those, those medications were overlap. And so my goal is to, a help pick a medication in that category that can help with both the arrhythmia and the blood pressure at the same time. On the other hand, the beta blocker medication category may not be the best choice for someone who's working with metabolic syndrome, right? If they don't have any other reasons, they need to be on a beta blocker for I might not choose that category. And so while the generic suggestion is to start with either an Ace inhibitor, a calcium channel blocker or a thiazide diuretic, we have a number of tools that we can use and we'll pick them based on on your other risk factors that we're also treating.

Matthew DeVane, MD: [00:12:01] Yeah. Think that's a AFib or an abnormal rhythms is one choice. Or if you have congestive heart failure, if you have diabetes, if you've had a heart attack in the past, all those things will help guide our first and second lines of medical therapy for your blood pressure. Good. The other thing I wanted to talk about as far as blood pressure treatment goes, is you. So you see the patient, you go ahead and start medications. How do you track the blood pressure success, the results? What are the things you tell a patient they need to do to help guide treatment next time they see you? Because the next time they'll see you maybe 4 or 6, 8, 10 weeks out because you wanted the medicine to kind of kick in and move around a little bit.

Christopher Chen, MD: [00:12:41] Yeah. So when they come back, I look for a couple of things. I want to know what symptoms they're having, right? I try to start just 1 or 2 medications at a time. So we know that if you're having side effects, what is coming from. So I want to know your symptom log. The second thing I want to know is, did your blood pressure is move. And so that's where home blood pressure monitoring really matters. I can get so much in the office, but I get a lot more from your blood pressure numbers, especially if they're taking well. And so when we come back for that 4 to 6-week clinic visit, I'll want to know a side effects feeling. Okay. And B, how did we do? Did we get to where we wanted to go? And if not, what are we going to do next?

Carolyn Lacey, MD: [00:13:20] And I think with the frequency that you're asking your patients to check the blood pressure a couple times a day, that will help you get a sense of what their average blood pressure is. And that's where we're trying to head for more, is the average blood pressure and try to avoid the outliers, the dips and the spikes just to make sure because we all have bad days and some days we're going to have low days, but we want to see kind of where are we, where have we settled out?

Christopher Chen, MD: [00:13:46] Yeah, absolutely. That's the importance of regular blood pressure taking. Right? Not just when you're feeling bad or when you're feeling good or right after you exercise when it looks the best. I want to know when it's average.

Matthew DeVane, MD: [00:13:55] And try to encourage people, people they will see. You know, once you start getting that much data and you're checking your blood pressure off and you are going to see some spikes and some dips. So I think as we get to those spikes and dips, I try to ease people's anxiety over that. And really the number itself isn't a big concern to me, whether on the high side or low side, but high numbers or low numbers with symptoms is sort of a category then where they should be reaching out to their doctor, Hey, I've got a headache, or I'm having chest pain when my blood pressure is this high or I'm almost passing out my blood pressure is this low. That's a bigger concern than any one number. Okay. So now we've seen a patient a few times. We've made some medication changes. The blood pressures are coming down, everybody's happy and they come back to you and they say, what's next? You know, how do we know when we're done titrating or adding medicines? What's normal or when are we happy with the blood pressure?

Christopher Chen, MD: [00:14:47] Yeah, that's such a good question because I think every patient is a little bit different, but we do set our goals at the beginning of treatment. So at the end of the first visit, hopefully, we'll say, Hey, look, this is your blood pressure goal. Our goal is either a systolic under 130 or a systolic under 120. We tend to be more aggressive, less than 120. And those patients that meet the Sprint trial criteria, the patients who are slightly higher risk for disease. And if we think there's not going to be much benefit, then we use a slightly higher target of 130. Now that goal is still a very generic goal. So once we reach our goal, we're happy. But that goal does vary by patient.

Matthew DeVane, MD: [00:15:29] It does. And so for me particularly, it depends on how they're tolerating their medicines, how good they are taking their blood pressure zone and reporting back. And then you get into this frailty in certain age where you just say, enough's enough. You know, I don't want to give you that fourth or fifth medicine. The blood pressures aren't quite perfect, but let's live with that because of the risk and benefit we're always trying to balance.

Carolyn Lacey, MD: [00:15:52] I think also, too, when you're when we're starting to come into. Place where everybody's feeling pretty comfortable just continuing the education of the non-pharmacologic things that they can do. Okay. So we're here. We're good. How can we expand some of these, either your exercise or doubling down on your nutrition, making sure your sleep is okay, and just all that continued education. It all builds.

Matthew DeVane, MD: [00:16:20] It does, yeah. And constant reminder to them about how it's a team effort. We're working in partnership with them to keep doing what they're doing. Yes, the pills are great. They will help a lot. But all the things you can do on your own, including the exercise and all the things which help your other cardiovascular risks like cholesterol numbers, diabetes, diabetes or metabolic syndrome, that all plays a role. So hopefully just keep working together.

Carolyn Lacey, MD: [00:16:44] Right, working together as a team is so it's so important. I have drugs I can throw at patients all day long. That's what I was trained to do is throw a lot of medications at patients. And I we have a lot of medications. But if you're not doing your homework and taking care of yourself, all those medications are just going to cause side effects and frustration. And so understanding that it's not just it is a team effort.

Christopher Chen, MD: [00:17:13] A couple of things about drugs, which I found was important. One is it's a little bit you know, patients hate being on a lot of drugs, but sometimes it's better to be on lower doses of multiple drugs rather than really high doses of a couple of drugs, because I mean, the majority of patients that are on high dose amlodipine that get leg swelling, right. The majority of patients who are on high doses of thiazide diuretics that get low potassium numbers when you're on high doses of medications, you're much more likely to experience those side effects. So maybe sometimes thinking that, hey, I'm on a little bit more medication, but lower doses of each, you're going to try to you're going to help avoid side effects. And that's something that I think is difficult to understand initially but make sense when we explain it to them.

Carolyn Lacey, MD: [00:18:01] Right. It's a mindset change. Oh, I need a new I need another pill, another pill. But when you start looking at it from the mindset of that one, too high gave me side effects. Okay? But it didn't. At a lower dose, it wasn't working well enough. Okay, well, let's add another one. Yeah.

Matthew DeVane, MD: [00:18:20] As you mentioned, the average patient with high blood pressure has already taken around three medicines and partly because of the reason you just mentioned, which is we like to use some lower doses to prevent side effects. When you're starting to get up to 4 or 5, 6 medicines for blood pressure and the medicine and the blood pressures are just not moving. You know, despite 5 medicines, your blood pressure is still 160 over 98 or whatever the number is. We call that kind of refractory hypertension. And that's a big concern. Can you just mean don't want to dive deep into the refractory stuff, because that's only a very small percentage of what we see. But, you know, we should be aware of it. And what do you tell your patients?

Christopher Chen, MD: [00:18:58] Absolutely. So there are things other than just genetics that can cause high blood pressure. And when you're reaching that category where you're trying everything and it's not working, we have to start looking. We will start looking at other causes of high blood pressure. Now, whether that's your renal arteries are very small or they're blocked up, right? You have maybe some hormonal issues that might be contributing to it. We start thinking, looking at other options for, hey, this is not just run-of-the-mill hypertension. How can we address it?

Matthew DeVane, MD: [00:19:29] Yeah, that's fortunately for us, that's a smaller percentage.

Carolyn Lacey, MD: [00:19:32] Very small percentage.

Matthew DeVane, MD: [00:19:34] I think the key is what we just talked about is working together. It's going to take modifiable risk factors, keep working on diet, exercise, probably going to take a combination of medications to get us where you need to be and a reminder that we are treating you because the outcomes data is real. You're going to have less strokes, less heart attacks, less congestive heart failure, and less death by especially if you have other risk factors by treating it aggressively. So just keep working on it. We'll get you there. Is there anything else you want to say about the, you know, your average patient on a couple of medicines with blood pressure problems that to wrap this thing up? Because I think we've covered so much over the last few episodes, I feel really comfortable that patients are going to learn so much. The key is just keep working with your doctor. Most, by the way, most of this is going to be done by the primary care doc. We as cardiologists, we're seeing them for other reasons, and then we just happen to dive into blood pressure or they get sent to us because blood pressure isn't easily being treated. So just as a reminder, always work with your you should get your blood pressure checks yearly with your doctor. Make sure you go to your annual physical by a home blood pressure monitor. That helps us a ton. I think. Big picture stuff that's really important.

Christopher Chen, MD: [00:20:46] Yeah, absolutely. It's so important. It's a team effort, right? Both between patient, our primary care docs us use an analogy of. The bonfire, right? I have a lot of squirt guns, but if you have a bonfire, that's what you're treating with your modifiable risk factors. If you're working on your weight, if you're working on your diet, that bonfire is going to get smaller, and don't need as many squirt guns. I got a big fire hose if I need to and I'll take care of the bonfire. But ultimately, if we can reduce the size of the fire, you're working on those modifiable risk factors, then my squirt guns don't need to be used.

Matthew DeVane, MD: [00:21:22] Excellent.

Carolyn Lacey, MD: [00:21:23] I like that.

Matthew DeVane, MD: [00:21:24] Well, we should. We be talking about fires in California, though?

Carolyn Lacey, MD: [00:21:27] We should.

Christopher Chen, MD: [00:21:27] Oh.

Matthew DeVane, MD: [00:21:29] Yeah. Now that we're in the.

Carolyn Lacey, MD: [00:21:31] I was thinking more of the bonfire on the beach. Oh, yeah, yeah. Right next to the ocean like that.

Matthew DeVane, MD: [00:21:35] Might. Yeah. Might use that analogy.

Carolyn Lacey, MD: [00:21:36] Yeah. Thank you.

Matthew DeVane, MD: [00:21:37] Yeah. Well, Dr. Chen, it's been absolutely wonderful talking to you about blood pressure. Your expertise is really appreciated here. Your patients are lucky to have you. And thank you so much for joining us.

Carolyn Lacey, MD: [00:21:46] Thank you. I have a question for you, Chris. So you know the phrase an apple a day keeps the doctor away. And I think as I've just been thinking myself about, oh, is it just the apple? Is there more to the apple? What is your apple when you're trying to see patients, because none of us like to come to the doctor, even those of us who are doctors, we don't like to go to the doctor. So if you can think of one thing that keeps the doctor away, what is that for you?

Christopher Chen, MD: [00:22:15] Yeah. So. KISS, right? keep it simple, stupid.

Matthew DeVane, MD: [00:22:20] Yeah, yeah, yeah.

Carolyn Lacey, MD: [00:22:21] That's a good one.

Christopher Chen, MD: [00:22:22] Just pick one thing, you'll work on it. And as those things get better, then you can pick the next thing. Keep it simple.

Carolyn Lacey, MD: [00:22:30] Oh, that's. That's good.

Matthew DeVane, MD: [00:22:31] That's so good because everybody's overwhelmed now. I mean, it's just. Yeah. Especially you're coming at them with numbers and diastolic and systolic and heart rate and you know, everything. Keep it, keep it simple. Keep it.

Carolyn Lacey, MD: [00:22:42] Simple.

Matthew DeVane, MD: [00:22:44] All right, Well, and that great note, we're going to say farewell and thank you so much.

Christopher Chen, MD: [00:22:49] Thank you, guys.

Matthew DeVane, MD: [00:22:53] This is Dr. Matt Devane, and on behalf of my co-host, Dr. Carolyn Lacey, and our partners at John Muir Health, we hope that you enjoyed this show and we really hope that you keep living heart smart.

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