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Ask the Doctor - February 2000 - Hypertension
Q: What is the initial treatment of high blood pressure, i.e., blood pressure above 140 mm Hg systolic or over 90 mm Hg diastolic.
Doctor: Initial lifestyle changes and medications, such as atenolol, a beta blocker, or low dose hydrochlorothiazide (HCTZ), a diuretic, for high blood pressure is usually prescribed by family practitioners and internists. This includes sodium reduction, weight loss, and alcohol restriction to less than 1 or 2 glasses per day.
Q: Who needs to see a specialist for hypertension treatment?
Doctor: If blood pressure is not reduced to goal of less than 140 systolic and less than 90 diastolic, then a second medication is usually added. If 4 weeks later blood pressure is still not at target, or if patients have side effects from medications, then they may be referred to me or another specialist for evaluation and treatment of difficult to control hypertension.
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Q: How soon do you see patients back for blood pressure check?
Doctor: If pressure is 160-170 (systolic)/100-110 or higher (diastolic), or if patients have diabetes, high cholesterol, if they smoke, or if they are severely overweight, then they may be referred for more intensive hypertension therapy. But in these cases, I like to bring the blood pressure down over a 1-, 2-, or 4-week period, depending on how high the blood pressure was initially.
Q: How quickly do you have to correct high blood pressure?
Doctor: One of the major problems I see is that some patient's blood pressure is reduced too quickly, which may cause people to become fatigued, tired, or less alert. Occasionally, patients may even become impotent. Good blood pressure control may require eventually titrating up to two or more medications. It is the responsibility of the physician to add, subtract, or combine medications or treatments to get patients blood pressure down to goal level. Unfortunately, recent studies demonstrate that many physicians do not change or add medications in over 50% of patients who are not controlled.
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Q: How useful are home blood pressure monitors?
Doctor: I like to encourage patients to use home blood pressure monitors. It sometimes help to record blood pressures in the morning, afternoon, and the evening, and look for patterns over a few days. In addition to finding time periods when patients may have worse hypertension, often times related to stress or medication schedule, checking home blood pressures eliminates over treatment from white coat hypertension in those 30% patients with reactive blood pressure in the doctor's office.
Ask the Doctor - April 2000 - Congestive Heart Failure
Congestive Heart Failure (CHF) is a common problem in patients with heart disease. It is the most common DRG diagnosis for Medicare cardiology patients. Symptoms include: Shortness of breath and fatigue. Leg swelling (edema) is a common sign. Causes include: heart attacks, hypertension, and valve disease.
Prognosis for CHF is improving with additional medications. Our present treatment consists of several drugs: beta blockers to improve survival, diuretics for relief of congestion, ACE-inhibitors (angiotensin converting enzyme inhibitors) to improve survival, digoxin (lanoxin) to decrease hospitalizations and improve well being, and sometimes spironolactone (aldactone) to further improve survival in the very sickest patients (Class IV CHF).
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Heart failure treatment centers focus on patient education often with extended visits with a nurse practitioner regarding use of scales to recognize early fluid accumulation, diet management regarding salt and fluids, and adjustment of medications. Our best results are achieved by adding on therapy, such as decreasing diuretics prior to adding blockers and then carefully titrating up doses of metoprolol or Calvedilol with visits every 2 to 8 weeks. Beta blockers require careful titration to avoid fatigue, slow heart rate, and low blood pressure. Metoprolol and Calvedilol have been tested and shown to improve survival.
Careful monitoring and heart imaging helps to guide therapy. echocardiography is a good non-invasive way to follow heart function in patients with CHF. Many patients with congestive heart failure will require cardiac catheterization to determine if coronary artery disease is the cause of their heart failure. It may improve the effectiveness of ACE- Inhibitors if aspirin can be discontinued in patients that do not have coronary artery disease.
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Citrus Valley Cardiology Medical Group, Inc., directed by Dr. Neil Doherty, is pleased to include these treatments of CHF and potential access to heart failure research trials. Its office is located at 412 West Carroll Avenue, Suite 210, Glendora, California 91741. Phone (626) 857-7344 for appointments.
The ATLAS trial showed at that higher doses of ace-inhibitors may be accompanied by less morbidity but survival was not necessarily better.
New therapies being studied include Omnipipralat (Vanlev by Bristol Myers-Squibb) angiotensin receptor blockers TNF receptor binding, and bi-ventricular pacing.
Heart to Heart - February 2000 -ALLHAT -Cholesterol & Hypertension
An interesting result of the ALLHAT investigation, of which I am regional San Gabriel Valley director, is the early termination of the doxazosin (Cardura) arm. The patient safety monitoring board decided there was a very low probability of finding a favorable outcome for the group assigned to doxazosin (Cardura) compared to those assigned to the diuretic (Chlorthalidone) arms, but there was a significant two-fold higher rate of congestive heart failure with Cardura compared with the diuretic arm.
This shows us the importance of the patient safety monitoring boards in research studies. While Pfizer has promoted the use of Cardura for many good theoretical Reasons, this is the first study that looked at a large group of patients to determine if it actually resulted in improved survival. No one anticipated that an inexpensive diuretic might have an advantage in patients with high risk for coronary artery disease, which are the types of patients recruited into the ALLHAT study, but this study showed that the diuretic had a lower rate of congestive heart failure than at least one of the drugs that was being studied. This probably reflects the value of diuretics for preventing congestive heart failure more than it reflects any deleterious effects of doxazosin but will certainly alter the practice of doctors caring for patients with high blood pressure.
Undoubtedly, there will be a flood of calls to change patients off Cardura in the next few months, which would be imprudent. Rather, it would be better to keep patients on Cardura, check their blood pressure and evaluate whether they develop congestive heart failure. Meanwhile, new patients with hypertension are best started on diuretics or beta blockers until results of the ALLHAT study let us know if alternative first line drug are really any better.
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Heart to Heart - April 2000
"The Cost of Cardiology" - Foothill Foundation
I just returned from the American College of Cardiology annual meeting in Anaheim, which attracted over 32,000 visitors. There were four buildings of new or improved cardiovascular machines, instruments, medicines, and books that merchants wanted doctors to buy as agents of our hospitals. The new tissue harmonic echocardiography machines, and digital workstations that go with them looked very appealing and I will share this information with the administrators at Foothill Presbyterian Hospital, who have previously indicated to me that an echo machine will be on the budget for next year.
Hospitals in southern California are generally running at a 2.5% loss the last two years, and most have put tight clamps on the pharmaceutical and purchase budgets, so the physicians are confronting the prospect that we are not going to get everything we want for our patients. Community philanthropy will need to play a growing role in major equipment purchases if we want to keep withholding from patients and still reach hospital financial targets.
The heart of the American College of Cardiology meetings are the scientific presentations. Dr. Jimmy Tseng, from Duke, presented the result of the ESPRIT trial, which showed Integrelin was associated with fewer complications, such as heart attacks, within 48 hours of STENTS. Its manufacturer, Cor Pharmaceuticals, is hoping that cardiologists will use their drug instead of Reopro, made by Johnson & Johnson, which cost $14000 per dose, resulting in a savings of $1000 per patient. Since only 25% of patients getting STENTS currently receive Reopro nationally, they are also hoping that more patients will be receiving Integrelin than used to receive Reopro. One of the economics lectures described how the savings could translate into hospital services. By way of analogy with Inter-Community campus, where 200 STENTS are placed annually, if that hospital used integrelin at $400 instead of Reopro at $14000, then the $200,000 savings could be used to pay salaries for 5 nurses or to help buy a new cath lab. This would pay for 1/5 of a new cath lab! I don't know where the generate the other $800,000 but I'm hopeful that major benefactor will step forward to meet this community need, because I cannot imagine that the administrators will find that much treasure in the operating budget.
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As data continues to show that acute PTCA has superior results to TPA, we may wish to look for ways to quickly transport patients from Foothill Presbyterian Hospital to Inter-Community campus for urgent cardiac catheterization. There also may be a role for small doses of Reopro or Integrelin, TPA and Lovenox (more costs) in these patients.
We can't lose sight of what we are trying to accomplish in cardiology because of the cost of the mission. I met a lot of old friends and learned a great deal in several areas of cardiology at this 4-day meeting, but can't fit it all into one column. As our group grows and our importance in the East San Gabriel Valley develops, I think we need to understand the impact of economics on the services that we can offer, and seek to have more community members understand the choices we have to make.
Dr. Doherty is a member of the Foothill Foundation, which seeks charitable donations to enhance hospital services to the community. Questions regarding the Foundation can be directed through Jill Donuhue at 857-3349 .
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