Welcome to Straight Talk on Health.I’m your host Dr. Chet Zelasko. Straight Talk on Health is a joint production with WGVU in Grand Rapids MI. I examine the practical application of health information. Nutrition. Exercise. Diet. Supplementation. I look at the science behind them, and let you know whether it’s something to consider or not. You can check out other things that I do on my website Drchet.com and sign up for my free emails.
My brother-in-law recently asked me to watch a video from someone claiming to be a doctor that specializes in blood pressure treatment. The purpose of the video was to demonstrate, no, that’s not quite right. It was to raise doubt in treating HBP to the latest standards set by various heart medical associations. Why? Because there could beserious side effects to meet the new standards for BP control. What standards?
The standards set by the American College of Cardiology and American Heart Association in 2017 recommended a BP target of less than 130/80 mmHg for adults aged 65 years or older. The recommendations can be set greater than 130 mm Hg for systolic BP if the individual has other diseases and conditions or are too frail for treatment. Remember, those are the standards that were set in 2017. The reason was the result of the SPRINT trial, supported later by the STEP trial. Doesn’t that sound interesting? We’re Stepping and Sprinting. Let’s take a look at the studies to get some perspective but first, what did the expert say?
He went to great length to talk about the hazards of lowering BP too low, by definition, less than 120 mm Hg systolic, in an aging population. The side effects could be lightheadedness, dizziness, feeling unsteady, leg cramps caused by electrolyte imbalance, and systolic BP lower than 100 mm also known as hypotension. He pointed out that the SPRINT trial excluded those people who had strokes, diabetes, dementia, advanced kidney disease, or were considered too frail. We’ll come back to him later. On to the trials.
The purpose of the SPRINT Trial was to test the hypothesis that stronger control of BP would provide more benefit in terms of deaths, heart attacks and strokes. Specifically, to compare treatments to reach a systolic blood- pressure target of less than 120 mm Hg, as compared with a target of less than 140 mm Hg but greater than 120 mm Hg. They tracked the number of medications subjects in each group took and they also monitored serious adverse events. The results showed that there were fewer CV events in the subjects who increased medications to get their systolic BP below the 120 mm mark.
Were there more Serious Adverse Events in the 120 mm Hg group? Yes. The side effects including hypotension (low blood pressure), syncope (fainting), electrolyte abnormalities (primarily sodium}, and acute kidney injury or failure in the intensive- treatment group than in the standard 140 mm Hg treatment group. That was true. But when you examine the actual data in the supplemental materials, you find that the number of actual cases of fainting were 94 in the intense treatment group vs. 44 in the normal treatment group. Out of 4600 subjects in each treatment group. Over 3.3 years. The other serious adverse events were similar—higher in the intense treatment group—and lower in the normal group. The data from the STEP trial the showed the same benefits in CV events in about the same number of subjects over 4 years of follow-up. However, there no differences between the treatment groups related to SAE with the exception of hypotension, confirming the results of the SPRINT Trial which was used to set the standard practice.
There are a few things that stick out to me before we get back to our BP doc. While there were more SAE when the subjects were treated with more medications, they were generally of a minor nature. Fainting can be serious and stressing the kidneys is not desirable. Remember back to the doc, pointing out those excluded in this trial? The people with strokes and other diseases and conditions? That’s exactly what the purpose of the SPRINT trial was supposed to do: eliminate confounding variables. Why? Isn’t that wrong? No and the reason is that there were already several studies that looked at people who had diabetes, strokes, heart attacks, and a myriad of other problems. The intent was to look at the healthiest group of older subjects to see how they responded to more treatment for their hypertension.
Maybe this will put things in perspective. When you examine the Supplemental Data for each study, it lists the actual number of events that happened, not just whether they were significantly different or not. While there were differences in SAE, the were infrequent. Take the worst possible scenario. In my opinion that would be kidney injury or kidney damage. There were 96 cases in the high treatment group and 36 cases in the standard treatment group in the SPRINT Trial. That’s sounds really bad and I’m not suggesting it isn’t. But in over 4600 subjects in each group, over a period of 3.3 years, that hardly seems like people were dropping over from the higher treatment.
I don’t really understand why he took such a confrontational view of the studies. He summarized the papers accurately as to number of subjects, methods, and results—with the exception of the SAE. I think he overdramatized the potential side effects but to what end? He wants a personalized program for every individual who has HT. But when you read the actual guidelines given by the ACC/AHA, they give the same warnings for people with severe adverse events as he does when he talks about controlling your own blood pressure. It’s not new; it’s exactly what physicians are supposed to do. The question of why some physicians only follow written protocol has more to do with the quality of the physician. But that may also reflect the patients as well.
The reason these studies were conducted was to find out if increasing pharmaceutical solutions can make up for what patients refuse to do: take better care of themselves by eating better, losing weight, and most importantly, exercising. That’s at the beginning of almost every research paper on using more medications.
From my perspective, there are two issues with the trials and indirectly, with the BP doc’s comments. There was no assessment of the fitness of the individuals and no measures of fitness in either study. That’s the glaring issue that I see. In research I’ve done as well as many others, changes in BP can happen less than a week after beginning an exercise program-regardless of the age of the individual. If that data had been collected, the number of SAE may have been lower in the high BP subject group and the reductions in CVD events may also have been lower. Oh, you’re surprised that people who exercise regularly could have very high systolic BP? Of course they could because part of BP control is genetic. Exercise could have added additional benefit but we don’t know because no one collected data on it.
Finally, and perhaps more importantly, is the additional effort warranted? Are we just extending life or are we really saving lives? Quality of life is absolutely important and should be considered by the treating physician. Discussion with the patient and family should include the potential of SAE in order to get the potential reduction in cardiac events from 2.19% to 1.65% over 3.3 years. The risk of a reducing a major cardiac event through more medications by just about one-half percent may not be worth the price to everyone. Again, are we saving lives or are we just extending life.
But he did get one thing correct. Each person should be treated like an individual by their physician. Maybe that’s the BP docs real message: every person realizing that they have a choice. I can’t argue with that.
That’s all the time I have for this episode. If you like this podcast, please hit the share button and tell your friends and colleagues about it. Until next time, this is Dr. Chet Zelasko saying health is a choice. Choose wisely today and every day.
References:
1. N Engl J Med 2015;373:2103-16.
2. N Engl J Med 2021;385:1268-79.
