Wednesday, 2 December 2015

ClinicSpeak & BrainHealth: what is your blood pressure?

When last have you had your blood pressure checked? #MSBlog #MSResearch #BrainHealth

"Prof Gold suggested to me that our 'Brain Health' campaign should have been named the 'Save Brain' campaign instead. He thinks as a term Brain Health is limp and that Saving Brain is more impactful from a public health perspective. What do you think?"


"Up until now we have tended to focus the campaign on the delays in diagnosis, getting referred to an MS expert promptly, starting a DMT early, having your disease activity monitored and having the option of rapid escalation to more effective treatments, or flipping the pyramid and accessing this treatment early. However, a large part of the Brain Health campaign related to lifestyle issues and co-morbidities. Today the focus is on hypertension."

"When last have you had your blood pressure checked? Are you hypertensive?"

"The following study published in the New England Journal of Medicine shows that people with hypertension with intensive blood pressure control (<120mmHg) do better than those with less intensive control of blood pressure (<140mmHg). We have to assume the same outcomes apply to pwMS and that the link between blood pressure control and MS progression is driven by the complications of high blood pressure. I say this knowing that there is some data supporting certain classes of antihypertensives as being disease-modifying independently of their effect on blood pressure. The downside of lowering your blood pressure too much is that the people in the intensive BP control arm had more serious adverse events that included light-headedness and fainting, altered renal function, including renal failure, but interestingly not injurious falls. The latter may not apply to pwMS who may be at higher risk of falls due to their MS, i.e. lower limb weakness and unsteadiness of gait due to damage to their balance and walking centres. Therefore this study should ideally be repeated in pwMS who have hypertension; this is unlikely to happen prospectively but may emerge from registry data."


"Do you need to see you doctor to have your blood pressure checked? No. A large number of pharmacies offer this as a free service. Many of you may have access to home BP machines that either work on your wrist or arms. The message here is to get your BP measured. Having a normal blood pressure will reduce the chance of vascular disease, small or mini-strokes, damaging your brain and speeding up your progression. Blood pressure control needs to be viewed as one of the components of MS management that contributes to the holistic management of the disease."

The SPRINT Research Group. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2015; 373:2103-211.

BACKGROUND: The most appropriate targets for systolic blood pressure to reduce cardiovascular morbidity and mortality among persons without diabetes remain uncertain.

METHODS: We randomly assigned 9361 persons with a systolic blood pressure of 130 mm Hg or higher and an increased cardiovascular risk, but without diabetes, to a systolic blood-pressure target of less than 120 mm Hg (intensive treatment) or a target of less than 140 mm Hg (standard treatment). The primary composite outcome was myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes.

RESULTS: At 1 year, the mean systolic blood pressure was 121.4 mm Hg in the intensive-treatment group and 136.2 mm Hg in the standard-treatment group. The intervention was stopped early after a median follow-up of 3.26 years owing to a significantly lower rate of the primary composite outcome in the intensive-treatment group than in the standard-treatment group (1.65% per year vs. 2.19% per year; hazard ratio with intensive treatment, 0.75; 95% confidence interval [CI], 0.64 to 0.89; P<0.001). All-cause mortality was also significantly lower in the intensive-treatment group (hazard ratio, 0.73; 95% CI, 0.60 to 0.90; P=0.003). Rates of serious adverse events of hypotension, syncope, electrolyte abnormalities, and acute kidney injury or failure, but not of injurious falls, were higher in the intensive-treatment group than in the standard-treatment group.

CONCLUSIONS: Among patients at high risk for cardiovascular events but without diabetes, targeting a systolic blood pressure of less than 120 mm Hg, as compared with less than 140 mm Hg, resulted in lower rates of fatal and nonfatal major cardiovascular events and death from any cause, although significantly higher rates of some adverse events were observed in the intensive-treatment group. (Funded by the National Institutes of Health; ClinicalTrials.gov number,NCT01206062.)

12 comments:

  1. Hi! My father RIP had diabetes and issues with BP. He was a man ahead of his time. Born Jewish in Germany Pre WW II he was part of "Kindred Transport" where youngsters from Germany were shipped of to England and raised on boarding houses as the Nazi's were coming to power. He lived the Battle of Britain as a young boy. In his life he came to the USA as a young teen, made a life, raised a family, never saw color, race or spiritual belief as vices to be fought over but instead diversity to be cherished.

    His BP issues later in life caused problems. He managed his diabetes for the most part himself. While God took my father incompetence in a medical system sped it along a bit. He was in rehab and a pressure sore on his foot developed due to not being moved. That sore eventually took him.

    He was a very very smart man.

    Towards Brain health I could only imagine what he would say. Never stop learning and exercising your brain until the day it is no longer of use to be sure.

    "Brain Health" as a term, its a low impact term.

    "Save Brain Campaign" to me, its again not personal.

    There is a great deal that can be said in few words. Towards Brain health it needs have an individual personal impact preferably hard hitting.

    Off the top of my head not given much time think and of course you need a explanatory tagline.

    Global Brain Domain Campaign

    Your Brain Matter

    A Brain Campaign (ABC)

    Accelerated Brain Campaign (ABC)

    Accelerate Brain Care (ABC)

    I am sure others may come to mind (no pun intended)

    Whatever you all decide on or if you want me really think on a term it should grab the potential readers as it is marketing and if there is anything we can do to help via our web venue by all means just let us know.

    ReplyDelete
    Replies
    1. "Don't let your Brain go down the Drain"

      Delete
  2. "The most appropriate targets for systolic blood pressure to reduce cardiovascular morbidity and mortality among persons without diabetes remain uncertain."
    This "Background" statement at the head of this article absolutely sums it up. Despite the findings in the study cited above, there is new research emerging which is showing that as people age a slight increase in blood pressure is pretty normal, and that unless there are other comorbid risks for cardiovascular problems, these people actually do better WITHOUT being treated for their mild hypertension. Losing a bit of excess avoirdupois and improving fitness levels is far better for lowering blood pressure for the majority of people than medications (although this is a bit hard to do if MS stops you from being able to exercise).

    It's sounding a bit too much like the progressive lowering of "acceptable" cholesterol levels over time which has resulted in many doctors putting many otherwise perfectly healthy people onto statins - with all of their attendant side effects. The more that fairly normal ageing changes become turned into "medical conditions" the more money Big Pharmas of all creeds and colours can make for their shareholders.

    ReplyDelete
  3. Further to a comment I just posted - viewing the article elsewhere reveals the following disclosure:
    "The SPRINT trial was supported by interagency grants from the National Institutes of Health (NHLBI, NIDDKD, NIA, and NINDS). Azilsartan and azilsartan HCL were donated by Takeda Pharmaceuticals International and Arbor Pharmaceuticals. Neither company had any other role in the study."

    ReplyDelete
  4. Better still than just checking your blood pressure, many GP practices offer a thorough health check and record your 'Qrisk', your chance of a CV event (stroke, heart attack etc) within the next 10 years. You can't change your family history or what you did in the past but you can eat healthily and exercise.
    The problem is, of course, exercise gets more difficult as MS progresses. How do you get a good work out when your legs won't hold you up?! How do you keep your BMI down when you can't get your heart rate up?
    It is so-o difficult but so important to try. Start as early as you can! Otherwise walking or standing will become even more challenging as you are asking your legs to support a larger load; a downward spiral of progressive disability not all directly down to MS.

    ReplyDelete
  5. There is much we can do to help lower blood pressure before the need for medication.
    Stop smoking, reduce salt intake, eat healthy, biofeedback and meditation.

    ReplyDelete
  6. I think some readers are missing the point; this is post is not necessarily about antihypertensive pharmaceuticals. It is about blood pressure control. It is about treating to target, i.e. keeping your systolic blood pressure below 120 mmHg. If you do that with diet, exercise, biofeedback or medication means the same thing. The point is getting your BP down. On a personal note I have done it with exercise and improved diet.

    ReplyDelete
    Replies
    1. This little black duck does not think the point has been missed. Part of the question that needs to be asked is whether the target that is being treated to is appropriate - i.e. medicalisation of what in some instances is normal change as people age. This is in no way denying that high BP is a significant health issue, but to be taking drugs to bring your blood pressure down to a target which is questionable is what I am taking issue with - and I note that the people in this study had systolic BPs from 130 upwards, while 130 is not that much above the optimum. Apart from excluding people with diabetes, there is no mention of what the "increased cardiovascular risk" factors were which were used to identify participants for the study. While no doubt detailed in the full article, the short extract above gives no details on the ages of the participants.

      Many years ago, I was put on BP lowering meds to treat "high" blood pressure which was only a bit above the optimum. I was not overweight, was healthy, but probably a bit unfit. What I now know to have been the first symptoms of my MS were exactly the same as the side effects of the last BP medication I was on. Consequently, this was a factor in the symptoms I was experiencing not being checked out further. When I stopped the medication my symptoms did not go away, but were not severe enough to prompt further investigation. I have not been on any BP meds for around 6 years and I get my current GP to check my BP each time I see her, and it is stable and within normal ranges for my age, despite the fact that my activity levels and fitness are now much reduced thanks to MS.

      The authors acknowledge that "Rates of serious adverse events of hypotension, syncope, electrolyte abnormalities, and acute kidney injury or failure, but not of injurious falls, were higher in the intensive-treatment group than in the standard-treatment group." For me this raises issues around undertaking a solid risk/benefit analysis for each patient with marginally high BP before prescribing medications which not only have side effects, but potential for other adverse outcomes.

      Delete
  7. I have had conversations with a few MSers and they do not think a healthy diet will help their MS at all, even in an indirect way. I think diet is very important.

    ReplyDelete
    Replies
    1. Of course diet matters - if you put dirty fuel in a car it doesn't go very well, sometimes not at all. The human body is no different.

      Unfortunately, there are so many people with barrows to push relating to their own perspectives on diet (in many cases with no real scientific foundations or based on weak correlations) that it is a minefield for Joe Average Person to try and navigate.

      It is also unfortunate that a considerable amount of current conventional thinking amongst tertiary trained dietary professionals is still based on "research" which was influenced by the food industry and other vested commercial interests in the latter half of the 20th century. While I am not a fan of any of the promoters of particular approaches to diet, the early chapters of Denies Minger's book Death by Food Pyramid do provide some interesting historical context to dirty work at the crossroads in relation to what are still widely promoted theories on diet, especially in relation to sugar consumption. Some of the research that was "discredited" in the development and promotion of the Food Pyramid is now being shown by newer research to have actually been correct. And we have more extreme viewpoints being espoused by T.Colin Campbell in the China Study, where dairy products and eating even a small amount of meat are supposedly the "root of all evil" and the cause of most of the diseases which plague modern western civilisations - including diseases such as MS.

      So it's no wonder the vast majority of the general public continues to consume whatever the slick marketing companies used by the food industry push at them. Colonel Sanders et al have a lot to answer for.

      COI - I have yet to sever my long standing and ongoing relationship with Mr Cadbury's products, but do wear a badge of pride that in 50+ years I have only ever eaten McDonalds twice.

      Delete
  8. How and why does low blood pressure lead to "altered renal function, including renal failure"?

    What if my BP is naturally very low without any medication?

    ReplyDelete
    Replies
    1. If you attend a renal clinic, the first thing they do is stick the BP cuff on your arm. BP and kidneys go together. The blood test tells whether your kidneys are working.

      Delete

Please note that all comments are moderated and any personal or marketing-related submissions will not be shown.