tag:blogger.com,1999:blog-7772182113499451603.post7784436256748731964..comments2024-03-27T10:50:53.692-05:00Comments on Real Psychiatry: Hypertension - Clinical and Historical Significance for Psychiatry George Dawson, MD, DFAPAhttp://www.blogger.com/profile/03474899831557543486noreply@blogger.comBlogger4125tag:blogger.com,1999:blog-7772182113499451603.post-54885394953694804302021-05-20T01:39:42.495-05:002021-05-20T01:39:42.495-05:00Full reference for above:
SPRINT Research Group, ...Full reference for above:<br /><br />SPRINT Research Group, Lewis CE, Fine LJ, Beddhu S, Cheung AK, Cushman WC, Cutler JA, Evans GW, Johnson KC, Kitzman DW, Oparil S, Rahman M, Reboussin DM, Rocco MV, Sink KM, Snyder JK, Whelton PK, Williamson JD, Wright JT Jr, Ambrosius WT. Final Report of a Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2021 May 20;384(20):1921-1930. doi: 10.1056/NEJMoa1901281. PMID: 34010531.George Dawson, MD, DFAPAhttps://www.blogger.com/profile/03474899831557543486noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-70064705124699829442021-05-16T00:08:28.976-05:002021-05-16T00:08:28.976-05:00In view of the above comments by Dr. Joe - I thoug...In view of the above comments by Dr. Joe - I thought I would post a couple of additional points.<br /><br />There is no singular right or wrong approach to this problem. That allows for plenty of contrasting views. In fact the IOM definition of Evidence Based Medicine takes into consideration how available evidence is applied to every clinical scenario for a specific patient and incorporates that patient's personal preferences, ability to follow up with the plan, and available resources.<br /><br />As a further example, I posted 2 additional blood pressure references (5 and 6 above). I have read 5 and am waiting for the text on 6. The authors suggest a very permissive approach to blood pressure unless there is clear evidence of end organ damage. As I have previously posted - I have been in that situation waiting for a legal intervention that might cause the patient to take their antihypertensive medication. Not all of those acute outcomes have been good even though I have personally seen other patients tolerate very high blood pressures for weeks at a time. That leads me to speculate that because of the well known health risk factors in people with severe mental illness - may tolerate blood pressure elevations less well than most medical and surgical patients. <br /><br />Those encounters clearly have an effect on my views about hypertension and how it must be assessed and treated.George Dawson, MD, DFAPAhttps://www.blogger.com/profile/03474899831557543486noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-20777825474319607652021-05-15T23:26:17.758-05:002021-05-15T23:26:17.758-05:00Appreciate you reading the blog and the detailed c...Appreciate you reading the blog and the detailed comments:<br /><br />In my experience emotional distress is an exaggerated cause for hypertension. I base that on extensive experience treating patients in acute care settings with severe problems. I have the time to look at the trends in that setting, and I know the way vitals are being determined. I certainly would prefer follow up with primary care, but due to the fragmented follow up that most of my patients receive - it is highly likely that I will make more blood pressure and heart rate determinations than they will get is a primary care setting. It may even be preferable to teach the patient to take their own BP and bring that in to their next appointment.<br /><br />Very current research confirms that 120/80 cutoff probably has better outcomes but the trade off is more side effects including syncope. Relative to the above post - the idea of BP being a polygenic determined quantitative rather than qualitative measure is relevant. Specifically the observation that hypertension yes or no is not being inherited but how high the blood pressure goes. In that case, the question becomes what group is more likely to proceed to various phenotypes suggested or even accelerated or malignant hypertension. I don't know the answer to that or at least any research answers. That said all treatment of complex polygenic disorders should involve a careful informed consent discussion and include the patient's preference.<br /><br />The SPRINT Research Group. Final report of a trial of intensive versus standard blood-pressure control. N Engl J Med 2021; 384: 1921-30.<br />George Dawson, MD, DFAPAhttps://www.blogger.com/profile/03474899831557543486noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-1924529657040138862021-05-15T22:11:34.470-05:002021-05-15T22:11:34.470-05:00I appreciate your extensive report on hypertension...I appreciate your extensive report on hypertension and the importance of following it. I have two comments. First, most of my patients come to their psychiatric appointment in a fair amount of emotional distress. Their blood pressure is routinely higher in my office than elsewhere. I advise them to follow their blood pressure outside my office. I continue to take readings, but given the pervasiveness of the confounding emotional distress I doubt the results have any relevance to their cardiovascular risk<br /><br />Second, I know that UpToDate uses cutoffs of 120 for systolic and 80 for diastolic blood pressure. However, my sense of the research is that the number needed to treat to reduce significant adverse effect from SBP <130 and DBP <90 is less than the number who are harmed by blood pressure medications. The page on treating mild hypertension on thennt.com site is dated, but they found a similar conclusion for SBP<140 and DBP<90. Dr Joehttps://www.blogger.com/profile/03536579611946585510noreply@blogger.com