DOCTORS’ LOUNGE
DOCTORS’ LOUNGE
80( a very high proportion of whom have hypertension) were excluded; participants with diabetes were also excluded! Considering that diabetes disproportionately affects older women, and that stroke, as the third leading cause of death for women, kills twice as many women as breast cancer annually, I conclude that the designers of this study( as happens so often in research) failed to care enough about gender differences.
Additionally, the Sprint Study was stopped with not even four years of follow-up because it was found that those whose blood pressure was maintained below 120 did better. They had reductions of 25 percent for heart attack, other acute coronary syndromes, stroke, heart failure hospitalization or cardiovascular related death.
However, those whose blood pressure was kept below 120 also had increased rates of blood pressure that was too low, with fainting, falls, acute kidney injury and electrolyte abnormalities: all in only 3.7 years of follow-up.
In contrast, the Glasgow work above had more than 14 years of follow-up and focused on the degree of variability of blood pressure. A higher degree of variance over time- seen most in women, with increasing age, and with chronic kidney disease and concurrent heart disease- was associated in all time frames with worsened cardiovascular and non-cardiovascular mortality. The highest levels of blood pressure carried more than a 40 percent increased risk of major vascular events compared to the lowest quartile. But since the study primarily focused on variability in blood pressure, the authors gave no recommendation for a specific systolic target.
The ACCORD trial, also with a predominance of men, tried to show that intensive blood pressure lowering was better than regular blood pressure lowering( that is less than 120 is better than less than 14 systolic) and participants achieved an average difference of 14 mmHg in systolic blood pressure lowering. The protocol allowed either manual or digital BP measurement. Five years’ follow-up failed to show any significant improvement from additional blood pressure lowering so far as time to cardiovascular death, to heart attack, or to stroke. However, it also showed a higher number of serious adverse events attributed to high blood pressure medications themselves, including“ events that were life-threatening, caused permanent disability or necessitated hospitalization.”
The ACCORDION trial followed up a subgroup of ACCORD participants for an additional 54 to 60 months; however, that 14 mmHg systolic BP difference narrowed to only 2 to 3 mm Hg in the follow-up group, and again there was only a nonsignificant reduction in the risk of stroke.
Dr. Wenger, writing in the October American Journal of Medicine, noted that the Sprint Study had both significant under enrollment of women and low event rates in women( in part due to the younger ages of women included) and that the study should have been continued for much longer than it was, to try to capture accurate data as women aged. She noted that women are more likely to take medications that affect blood pressure control including antidepressants, thyroid hormone, immunosuppressant and nonsteroidal medicines. She noted that African-American women are at least three times more likely to develop ACE inhibitor related coughs, and that more than half of Hispanic women over 60 have either metabolic syndrome or actual diabetes, both of which greatly increase the risk for heart attack, major stroke, vascular dementia and heart failure.
My recommendation is that you take each person’ s blood pressure yourself, and that the“ N of 1” study on blood pressure medication tolerability and effectiveness, for each person individually, is the best way to advise and design treatment. Marathon runners get high blood pressure too: just leading a healthy life cannot overcome the effects of the gene pool plus aging.
In the New Year, I have finally begun to carry around my very own manual blood pressure cuff, to save time, sanity and my own cerebral vessel plasticity, all of which have been endangered by the omnipresent plastic machines that purport to measure blood pressure digitally.
Dr. Barry practices Internal Medicine with Norton Community Medical Associates-Barret. She is a clinical associate professor at the University of Louisville School of Medicine, Department of Medicine.
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