Archive for September, 2015

High Blood Pressure: How Low Should We Go?

Tuesday, September 15, 2015 // Uncategorized

How low she one’s blood pressure be when being treated for hypertension?  That question has been debated for decades.  The last updated guidelines were in late 2014.  They created controversy by raising the optimal levels in patients 60 and over.  Here is a summary from Journal Watch:

December 30, 2014 JNC 8: Raising the Blood Pressure (and Ire) of Many Jamaluddin Moloo, MD, MPH Jamaluddin Moloo, MD, MPH

The Joint National Committee recommends that patients older than 60 be treated for hypertension only when systolic blood pressure exceeds 150 mm Hg. Jamaluddin Moloo, MD, MPHThe Joint National Committee (JNC) 8 guideline (published online in late December 2013 and printed in a February 2014 issue of JAMA) addresses blood pressure (BP) thresholds at which drug therapy should be initiated, BP targets during hypertensive treatment, and choice of antihypertensive agents (NEJM JW Gen Med Dec 24 2013).For patients younger than 60, JNC 8 specifies that drug therapy should be considered when diastolic BP is >90 mm Hg or systolic BP is >140 mm Hg. For older patients (age, ≥60), the diastolic BP threshold remains >90 mm Hg, but the systolic BP threshold is >150 mm Hg. Among people with diabetes or chronic renal disease, the threshold to initiate drug therapy is 140/90 mm Hg, and the goal for treatment is <140/90.In black patients, initial drug choices include thiazide-type diuretics or calcium-channel blockers (CCBs); in nonblack patients, initial drug choices were expanded (relative to JNC 7 recommendations) to include not just thiazide-type diuretics, but also CCBs, angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) — but not β-blockers. JNC 8 recommends that patients with chronic renal disease generally should be prescribed ACE inhibitors or ARBs.Compared with the JNC 7 writers, the JNC 8 writing committee drew its conclusions more strictly from randomized-trial evidence and limited the scope of the guideline to drug therapy for hypertension. The most controversial and contested recommendation is the higher threshold (systolic BP, >150 mm Hg) for people older than 60. Some experts, and the American Society of Hypertension, recommend a target this high only for patients older than 80 (NEJM JW Gen Med Dec 24 2013). – See more at:


Now the latest salvo comes from the NIH and a study that was stopped prematurely.  They issued a press release describing the results.  The problem is that it hasn’t yet be published and subjected to scrutiny as occurs with important clinical trials.  Here is the article from the New York Times:


Lower Blood Pressure Guidelines Could Be ‘Lifesaving,’ Federal Study Says

September 14, 2015 NIH: Aggressive Blood Pressure Management May Cut CV Events, Save Lives By Amy Orciari Herman Edited by André Sofair, MD, MPH

Reducing systolic blood pressure to below currently recommended targets may lower risk for cardiovascular events and death, according to findings from the NIH-funded SPRINT study announced on Friday.Some 9300 hypertensive adults aged 50 and older who were at high risk for heart disease or had kidney disease were randomized to one of two systolic BP targets: an aggressive target below 120 mm Hg, or a more conventional target below 140 mm Hg. Patients with diabetes or prior stroke were excluded.Participants were randomized between 2010 and 2013, and the trial was expected to go until 2017, but the researchers stopped it early after seeing the benefits of the intensive strategy. In that group, the risk for cardiovascular events was cut by nearly a third, and the mortality risk by almost a fourth, relative to conventional treatment.NEJM Journal Watch Cardiology’s Dr. Harlan Krumholz said: “Kudos to the NIH and the investigators for delivering on a challenging trial in this controversial area.The challenge for doctors and patients is to have patience because we only have the announcement at this point and lack the details to know how best to translate the study into practice.” – See more at:

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Book Review: Medical Quarterbacking

Wednesday, September 9, 2015 // Uncategorized

I haven’t read the book, but the review makes it sound interesting.

Medical Quarterbacking

Providers are drowning in patients. As a result, you need to fight tenaciously to make sure that you get the best care.

David A. Shaywitz

Sept. 8, 2015 7:25 p.m. ET


With gleaming hospitals, highly trained professionals, and ready access to new medicines and technologies, the American health-care system seems poised to provide the best care in the world—and sometimes it does. More often, explains Leslie D. Michelson in “The Patient’s Playbook,” people who are confronted by a serious illness discover that “there is no map.” There is no one with the time, information and stamina to coordinate, or “quarterback,” their care.

Mr. Michelson seeks to change all this. He isn’t a physician, but he has spent the past decade delivering what might be called concierge medical quarterbacking—helping patients, generally people with a high net worth, manage complex medical challenges. Now he’s ready to share his “playbook” with the rest of us.

The advice is often disarmingly simple. Prepare for illness when you are healthy. Get hold of your medical records. (You have a legal right to them.) Figure out which hospital you would want to go to in an emergency. He tells the harrowing story of parents who brought their jaundiced 2-day-old infant to the hospital where she was born, only to discover that the emergency-room staff there were used to adult patients and had minimal experience taking care of children.


The Patient’s Playbook

By Leslie D. Michelson
Knopf, 320 pages, $24.95
Mr. Michelson emphasizes the importance of a good primary-care physician—someone with whom you can have a relationship and who will orchestrate your care if you get sick. The challenge, he says, is that the typical primary-care physician sees 20 to 40 patients a day. How can such doctors, he wonders, “think clearly and carefully about each one?”

You might consider splurging for a primary-care physician in a concierge practice. If you want someone “who can give you an abundance of quality time at the drop of a hat,” Mr. Michelson writes, “then you should expect to pay extra for it.” But even if you cannot afford the concierge option, it is worth investing time in the selection process: develop a list of qualities you feel are important in a doctor, solicit recommendations, interview candidates. “Don’t start from the position that you can’t judge,” advises Mr. Michelson. For serious conditions, he counsels patients to seek out super-specialists—doctors who spend all their time thinking only about the disease you have. These experts tend to be found at top academic medical centers and are often deemed “in-network” by insurers, representing a rare health-care bargain.


Above all, Mr. Michelson implores patients to be intensely involved in their own care. Many people, when speaking with a doctor about a health problem, “behave as if they were powerless,” he writes. Some become deferential; others just want to leave as fast as possible. He urges patients instead to “bring their A-game” to the doctor’s office. Use a trusted resource like the National Institutes of Health or the UpToDate medical website to educate yourself about your condition; then, during your appointment, take notes and ask questions.

Vigilance is especially needed in hospital wards, where more than 10% of patients suffer a hospital-associated complication: a fall, an infection, an adverse drug reaction. Mr. Michelson’s counsel: Post a summary of your medical information near your bed and engage with the hospital staff so that you’re viewed as, say, a doting grandmother rather than merely the broken hip in Room 12B. Don’t take new medicines or submit to procedures in a hospital without understanding why they were ordered and insist that new symptoms—swelling, fever, pain—be promptly evaluated.

Why such intense oversight? The answer, Mr. Michelson suggests, is that while doctors may have entered medicine “to develop strong emotional bonds with people and to help them through health challenges,” providers now find themselves overwhelmed, drowning in patients, process and data. As a result, you need to monitor your own care attentively—and tenaciously fight to ensure you wind up with the most experienced surgeon or, after a biopsy, the most expert pathologist.

To his credit, Mr. Michelson advocates smart care, not more care. He devotes a chapter to the harms of unnecessary testing and gratuitous procedures, reminding readers that “overtreatment can be as dangerous as undertreatment.” A rush to treatment can also be a problem. Short of an emergency, it is important for patients, and doctors, to think things through. Mr. Michelson recounts the story of a man whose shortness of breath led him to a new doctor, a reflexively scheduled angiogram and the insertion of stents in his heart arteries well before a careful diagnosis had been made. The man’s problem, it turned out, wasn’t the heart but the lungs. The stent procedure was unnecessary.

While Mr. Michelson asserts that his various strategies deliver improved outcomes for patients, he supports this view with anecdotes, not data. Leading care organizations like Kaiser Permanente and Florida-based ChenMed would surely contend that their own patients do at least as well as the tiger patients that Mr. Michelson touts—without the extra financial and emotional costs that the Michelson approach would often seem to entail. But “The Patient’s Playbook” isn’t offering policy; it’s offering practical advice, preaching what many physicians and health-policy gurus practice when a loved one gets sick. It’s a timely reminder that, in our worthy effort to improve the health of populations, we should not lose sight of medicine’s primary goal: delivering the best possible care to each individual patient.

Dr. Shaywitz is chief medical officer of DNAnexus, a cloud genomics company, and a visiting scientist in the Department of Biomedical Informatics at Harvard.

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